Insurance (GIN) — Title 15. Health Insurance
Statutes in effect as of October 1, 2026.
Subtitle 1. General Provisions
Md. Code Ann., Ins. § 15-101 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–101LinkCopy Citation
This title does not apply to:
(1)
a policy of liability or workers’ compensation and employer’s liability insurance;
(2)
a group or blanket policy, except as otherwise provided in this title;
(3)
reinsurance; or
(4)
a life insurance, endowment, or annuity contract, or contract supplemental to a life insurance, endowment, or annuity contract that contains only those provisions relating to health insurance that:
(i)
provide additional benefits in case of dismemberment, loss of sight, or death by accident or accidental means;
(ii)
provide additional benefits for long-term home health care and long-term care in a nursing home or other related institution; or
(iii)
operate to safeguard the contract or supplemental contract against lapse or to provide a special surrender value, special benefit, or annuity in the event that the insured or annuitant becomes totally and permanently disabled, as defined by the contract or supplemental contract.
Md. Code Ann., Ins. § 15-102 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–102LinkCopy Citation
In this title, the word “insured” may not be construed to prevent a person other than the insured with a proper insurable interest from applying for and owning a policy covering the insured or from being entitled under that policy to any indemnities, benefits, and rights provided in the policy.
Md. Code Ann., Ins. § 15-103 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–103LinkCopy Citation
(a)
An insurer or nonprofit health service plan may not issue or deliver in the State an individual health insurance policy, or group health insurance policy covering a group of 1,000 lives or less, unless the policy or certificate is:
(1)
written in simplified language; and
(2)
approved by the Commissioner as complying with the simplified language standards adopted under subsection (c) of this section.
(b)
Subsection (a) of this section applies:
(1)
on or after January 2, 1992; or
(2)
on or after July 2, 1997, if the policy or certificate was approved by the Commissioner on or before January 1, 1992.
(c)
To establish simplified language standards for individual and group health insurance policies and certificates subject to this section, the Commissioner shall adopt regulations that are consistent with the Life and Health Insurance Policy Language Simplification Model Act adopted by the National Association of Insurance Commissioners.
Md. Code Ann., Ins. § 15-104 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–104LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Intensive care policy” means a health insurance policy that provides benefits only for treatment received in the specifically designated facility of a hospital that provides the highest level of care and is restricted to patients who are physically and critically ill or injured.
(3)
“Specified disease policy” has the meaning stated in § 15-109 of this subtitle.
(b)
In accordance with regulations that the Commissioner adopts, the Commissioner shall allow health insurance policies and policies of nonprofit health service plans to contain nonduplication provisions or provisions to coordinate coverage with:
(1)
other health insurance policies, including commercial individual, group, and blanket policies and policies of nonprofit health service plans;
(2)
subscriber contracts that are issued by health maintenance organizations; and
(3)
other established programs under which the insured may make a claim.
(c)
Notwithstanding subsection (b) of this section or any other provision of this article, an individual, group, or blanket health insurance policy, nonprofit health insurance policy, or nonprofit health service plan may not contain a nonduplication provision or provision to coordinate coverage with an individually underwritten and issued, guaranteed renewable, specified disease policy or intensive care policy, that does not provide benefits on an expense-incurred basis.
(d)
Health insurance policies and policies of nonprofit health service plans may not contain a provision that requires personal injury protection benefits under a motor vehicle liability insurance policy to be paid before benefits under the policies.
Md. Code Ann., Ins. § 15-105 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–105LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Breast implant” means a pocket or envelope that is surgically inserted under the skin and contains soft silicone gel, saline solution, or a combination of soft silicone gel and saline solution.
(3)
“Breast implant-related condition” means a condition that the federal Food and Drug Administration recognizes as possibly linked to breast implants.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section shall provide information to the Commissioner about the entity’s:
(1)
coverage for breast implant removals and breast implant-related conditions; and
(2)
preexisting condition provisions in policies for individuals with breast implants.
(d)
(1)
On request, the Commissioner shall make available to consumers and licensed physicians the information collected under subsection (c) of this section.
(2)
When providing the information, the Commissioner may include a statement that the Commissioner does not guarantee the accuracy of the information.
(3)
The Commissioner may set a fee to cover the cost of providing the information under paragraph (1) of this subsection.
(e)
A licensed physician may make available to a patient the information obtained from the Commissioner under subsection (d) of this section.
(f)
The Commissioner shall adopt regulations to carry out this section, including regulations that determine the extent and format of the information required under subsection (c) of this section.
Md. Code Ann., Ins. § 15-106 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–106LinkCopy Citation
(a)
(1)
An insurer under a contract that provides an individual with home medical equipment pursuant to an individual, group, or blanket health insurance policy or certificate that is delivered or issued for delivery in the State and that provides benefits on an expense-incurred basis:
(i)
shall pay the home medical equipment provider directly if the insured has executed an assignment of benefits; and
(ii)
subject to the copayment and deductible provisions in the insurance contract, may not require the home medical equipment provider to accept less than the agreed monthly rental amount for each month in which benefits are payable under the insurance contract.
(2)
A nonprofit health service plan under a contract that provides a subscriber with home medical equipment pursuant to a health insurance policy or certificate that is delivered or issued for delivery in the State and that provides benefits on an expense-incurred basis:
(i)
shall pay the home medical equipment provider directly if the contract, policy, or certificate of insurance provides for direct payment;
(ii)
may pay the home medical equipment provider or the subscriber receiving the home medical equipment, if the contract, policy, or certificate of insurance does not require direct payment; and
(iii)
may not require the home medical equipment provider to accept less than the agreed monthly rental amount for each month that use of the home medical equipment is authorized by the nonprofit health service plan.
(b)
Authorization may not be terminated until both the provider and beneficiary of the home medical equipment have been notified that authorization is terminated.
(c)
(1)
Rented home medical equipment and services may be purchased with the consent of the provider and insurer if:
(i)
on the insurer’s request either before the initial election to rent the equipment or on the insurer’s receipt of the initial claim from the provider, the purchase price and rental price of the equipment were disclosed to the insurer; and
(ii)
there is no material change in the medical condition of the insured, as certified by the attending physician.
(2)
Rented home medical equipment and services may be purchased with the consent of the provider and nonprofit health service plan in accordance with the benefits available under the applicable health insurance policy or certificate.
Md. Code Ann., Ins. § 15-107 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–107LinkCopy Citation
(a)
This section applies to insurers and nonprofit health service plans that issue or deliver individual, group, or blanket health insurance policies in the State.
(b)
At least 30 days before the change is effective, an entity subject to this section that provides pharmaceutical benefits shall notify in writing all pharmacies under contract with the entity of any of the following changes in the pharmaceutical benefit program rules or requirements:
(1)
exclusion of coverage for classes of drugs as specified by the contract;
(2)
changes in prior or preauthorization procedures; or
(3)
selection of new prescription claims processors.
(c)
An entity subject to this section that fails to provide advance notice under subsection (b) of this section shall honor and pay in full any claim under the program rules or requirements that existed before the change for 30 days after the postmarked date of the notice.
Md. Code Ann., Ins. § 15-108 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–108LinkCopy Citation
Each insurer that issues or delivers individual, group, or blanket health insurance policies in the State shall establish record keeping procedures that allow review for overutilization and abuse of the use of hospital, health, and medical services that may result from the actions or activities of the policyholders or certificate holders of the insurer or the providers of hospital, health, and medical services to the insured individuals.
Md. Code Ann., Ins. § 15-109 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–109LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Loss ratio” means the ratio of losses incurred to premiums earned on policies that are issued, delivered, or renewed in the State.
(3)
“Specified disease policy” means a health insurance policy that provides:
(i)
benefits only for a disease or diseases specified in the policy or for a treatment unique to a specified disease or diseases; or
(ii)
additional benefits for a disease or diseases specified in the policy or for treatment unique to a specified disease or diseases.
(b)
This section applies to each individual, group, or blanket health insurance policy or nonprofit health service plan that is issued or delivered in the State.
(c)
To administer §§ 12-203, 12-204, and 12-205 of this article, the Commissioner shall establish a minimum loss ratio in accordance with generally accepted actuarial principles with respect to specified disease policies.
Md. Code Ann., Ins. § 15-110 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–110LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Health care practitioner” has the meaning stated in § 1–301 of the Health Occupations Article.
(3)
“Health care service” has the meaning stated in § 1–301 of the Health Occupations Article.
(4)
“Prohibited referral” means a referral prohibited by § 1–302 of the Health Occupations Article.
(b)
This section applies to insurers and nonprofit health service plans that issue or deliver individual or group health insurance policies in the State.
(c)
An entity subject to this section may seek repayment from a health care practitioner of any money paid for a claim, bill, or other demand or request for payment for health care services that the appropriate regulatory board determines were provided as a result of a prohibited referral.
(d)
Each individual and group health insurance policy that is issued for delivery in the State by an entity subject to this section and that provides coverage for health care services shall include a provision that excludes payment of any claim, bill, or other demand or request for payment for health care services that the appropriate regulatory board determines were provided as a result of a prohibited referral.
(e)
An entity subject to this section shall report to the Commissioner and the appropriate regulatory board any pattern of claims, bills, or other demands or requests for payment submitted for health care services provided as a result of a prohibited referral within 30 days after the entity has knowledge of the pattern.
(f)
(1)
Notwithstanding any other provision of this section, an entity subject to this section that reimburses for health care services is not required to audit or investigate a claim, bill, or other demand or request for payment for health care services to determine whether those services were provided as a result of a prohibited referral.
(2)
An audit or investigation of a claim, bill, or other demand or request for payment for health care services to determine whether those services were provided as a result of a prohibited referral is not grounds to delay payment or waive the provisions of §§ 15–1004 and 15–1005 of this title.
(g)
In accordance with § 1–305 of the Health Occupations Article, an entity subject to this section may seek a refund of a payment made for a claim, bill, or other demand or request for payment that is subsequently determined to be for a health care service provided as a result of a prohibited referral.
Md. Code Ann., Ins. § 15-111 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–111LinkCopy Citation
(a)
Each payor shall cooperate fully in submitting reports and claims data and providing any other information to the Maryland Health Care Commission in accordance with Title 19, Subtitle 1 of the Health - General Article.
(b)
The Commissioner shall report to the Maryland Health Care Commission in a timely manner the name and address of each payor that is assessed a fee under § 19–111 of the Health – General Article.
Md. Code Ann., Ins. § 15-112 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–112LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Accredited hospital” has the meaning stated in § 19–301 of the Health – General Article.
(3)
“Ambulatory surgical facility” has the meaning stated in § 19–3B–01 of the Health – General Article.
(4)
“Behavioral health care services” has the meaning stated in § 15–127 of this subtitle.
(5)
(i)
“Carrier” means:
(1)
an insurer;
(2)
a nonprofit health service plan;
(3)
a health maintenance organization;
(4)
a dental plan organization; or
(5)
any other person that provides health benefit plans subject to regulation by the State.
(ii)
“Carrier” includes an entity that arranges a provider panel for a carrier.
(6)
“Credentialing intermediary” means a person to whom a carrier has delegated credentialing or recredentialing authority and responsibility.
(7)
“Enrollee” means a person entitled to health care benefits from a carrier.
(8)
“Group model health maintenance organization” has the meaning stated in § 19–713.6(a) of the Health – General Article.
(9)
“Health benefit plan”:
(i)
for a group or blanket plan in the large group market, has the meaning stated in § 15–1401 of this title;
(ii)
for a group in the small group market, has the meaning stated in § 31–101 of this article; and
(iii)
for an individual plan, has the meaning stated in § 15–1301 of this title.
(10)
(i)
“Health care facility” means a health care setting or institution providing physical, mental, or substance use disorder health care services.
(ii)
“Health care facility” includes:
(1)
a hospital;
(2)
an ambulatory surgical or treatment center;
(3)
a skilled nursing facility;
(4)
a residential treatment center;
(5)
an urgent care center;
(6)
a diagnostic, laboratory, or imaging center;
(7)
a rehabilitation facility; and
(8)
any other therapeutic health care setting.
(11)
“Hospital” has the meaning stated in § 19–301 of the Health – General Article.
(12)
“Network” means a carrier’s participating providers and the health care facilities with which a carrier contracts to provide health care services to the carrier’s enrollees under the carrier’s health benefit plan.
(13)
“Online credentialing system” means the system through which a provider may access an online provider credentialing application that the Commissioner has designated as the uniform credentialing form under § 15–112.1(e) of this subtitle.
(14)
“Participating provider” means a provider on a carrier’s provider panel.
(15)
“Provider” means a health care practitioner or group of health care practitioners licensed, certified, or otherwise authorized by law to provide health care services.
(16)
“Provider directory” means a list of a carrier’s participating providers and participating health care facilities.
(17)
(i)
“Provider panel” means the providers that contract either directly or through a subcontracting entity with a carrier to provide health care services to the carrier’s enrollees under the carrier’s health benefit plan.
(ii)
“Provider panel” does not include an arrangement in which any provider may participate solely by contracting with the carrier to provide health care services at a discounted fee–for–service rate.
(b)
(1)
Subject to paragraph (3) of this subsection, a carrier that uses a provider panel shall:
(i)
if the carrier is an insurer, nonprofit health service plan, health maintenance organization, or dental plan organization, maintain standards in accordance with regulations adopted by the Commissioner for availability of health care providers to meet the health care needs of enrollees; and
(ii)
establish procedures to:
(1)
review applications for participation on the carrier’s provider panel in accordance with this section;
(2)
notify an enrollee of:
(A)
the termination from the carrier’s provider panel, including when the provider elects to terminate participation from the provider panel, of the primary care provider that was furnishing health care services to the enrollee and any provider of behavioral health care services for whom the carrier has received a claim for services performed on the enrollee within the 3 months immediately preceding the date of the termination; and
(B)
the right of the enrollee, on request, to continue to receive health care services from the providers described in item A of this item for up to 90 days after the date of the notice of termination of the provider from the carrier’s provider panel, if the termination was for reasons unrelated to fraud, patient abuse, incompetency, or loss of licensure status;
(3)
notify primary care providers on the carrier’s provider panel of the termination of a specialty referral services provider;
(4)
verify with each provider on the carrier’s provider panel, at the time of credentialing and recredentialing, whether the provider is accepting new patients and update the information on participating providers that the carrier is required to provide under subsection (n) of this section; and
(5)
notify a provider at least 90 days before the date of the termination of the provider from the carrier’s provider panel, if the termination is for reasons unrelated to fraud, patient abuse, incompetency, or loss of licensure status.
(2)
The provisions of paragraph (1)(ii)4 of this subsection may not be construed to require a carrier to allow a provider to refuse to accept new patients covered by the carrier.
(3)
For a carrier that is an insurer, a nonprofit health service plan, or a health maintenance organization, the standards required under paragraph (1)(i) of this subsection shall:
(i)
ensure that all enrollees, including adults and children, have access to providers and covered services without unreasonable travel or delay;
(ii)
(1)
include standards that ensure access to providers, including essential community providers, that serve predominantly low–income and medically underserved individuals; or
(2)
for a carrier that provides a majority of covered professional services through physicians employed by a single contracted medical group and through health care providers employed by the carrier, include alternative standards for addressing the needs of low–income, medically underserved individuals; and
(iii)
except for a carrier that is a group model health maintenance organization, ensure that all enrollees have access to local health departments and covered services provided through local health departments, including behavioral health care services, to the extent that local health departments are willing to participate on a carrier’s provider panel.
(4)
The notice required under paragraph (1)(ii)2 of this subsection shall include:
(i)
contact information that the enrollee may use to direct comments or concerns to the carrier regarding the termination of the provider from the carrier’s provider panel;
(ii)
instructions on how the enrollee may notify the carrier of the need for transitional care as described in paragraph (1)(ii)2B of this subsection by submitting a uniform form developed by the Commissioner under subsection (y)(4) of this section; and
(iii)
the telephone number and e–mail address for the office in the Administration that is responsible for receiving and responding to complaints.
(c)
(1)
This subsection applies to a carrier that:
(i)
is an insurer, a nonprofit health service plan, or a health maintenance organization; and
(ii)
uses a provider panel for a health benefit plan offered by the carrier.
(2)
(i)
On or before July 1, 2018, and annually thereafter, a carrier shall file with the Commissioner for review by the Commissioner an access plan that meets the requirements of subsection (b) of this section and any regulations adopted by the Commissioner under subsections (b) and (d) of this section.
(ii)
If the termination of a provider or health care facility from the carrier’s provider panel will result in a material change to the access plan, the carrier shall:
(1)
subject to subparagraph (iv) of this paragraph, notify the Commissioner of the impending termination at least 60 days before the anticipated date of termination;
(2)
have a continuing obligation to update and supplement the initial and subsequent notifications until the termination is effective or an agreement is reached with the provider or health care facility; and
(3)
subject to subparagraph (v) of this paragraph, within 5 business days after the effective date of the termination, file with the Commissioner an update to the existing access plan for review by the Commissioner.
(iii)
The Commissioner may order corrective action if, after review, the access plan is determined not to meet the requirements of this subsection.
(iv)
The notice required under subparagraph (ii)1 of this paragraph shall be provided if:
(1)
the provider or health care facility provides advance notice to the carrier of its intention to terminate participation in the carrier’s provider panel;
(2)
the carrier provides advance notice to the provider or health care facility of the carrier’s intention to terminate the provider or health care facility from the carrier’s provider panel;
(3)
the current term of the existing network participation contract between the carrier and the provider or health care facility is set to expire within 60 days and an agreement to extend or renew the contract has not been reached; or
(4)
the carrier possesses other information that it reasonably determines is an indication that termination of the provider or health care facility from the carrier’s provider panel is likely in the next 60 days.
(v)
The update to the existing access plan required to be filed under subparagraph (ii)3 of this paragraph is required to include only information related to:
(1)
the provider specialty types affected by the material change; and
(2)
unless the network as a whole experienced a 10% reduction, the geographic areas where enrollees were affected by the material change.
(vi)
The Commissioner may impose a fine of $5,000 per day for each day past 5 business days that the carrier fails to file an update to the existing access plan as required by subparagraph (ii)3 of this paragraph.
(3)
(i)
In accordance with § 4–335 of the General Provisions Article, the Commissioner shall deny inspection of the parts of the access plan filed under this subsection that contain confidential commercial information or confidential financial information.
(ii)
The regulations adopted by the Commissioner under subsection (d) of this section shall identify the parts of the access plan that may be considered confidential by the carrier.
(4)
An access plan filed under this subsection shall include a description of:
(i)
the carrier’s network, including how telemedicine, telehealth, or other technology may be used to meet network access standards required under subsection (b) of this section;
(ii)
the carrier’s process for monitoring and ensuring, on an ongoing basis, the sufficiency of the network to meet the health care needs of enrollees;
(iii)
the factors used by the carrier to build its provider network, including the criteria used to select providers for participation in the network and, if applicable, place providers in network tiers;
(iv)
the carrier’s efforts to address the needs of both adult and child enrollees, including adults and children with:
(1)
limited English proficiency or illiteracy;
(2)
diverse cultural or ethnic backgrounds;
(3)
physical or mental disabilities; and
(4)
serious, chronic, or complex health conditions;
(v)
(1)
the carrier’s efforts to include providers, including essential community providers, in its network who serve predominantly low–income, medically underserved individuals; or
(2)
for a carrier that provides a majority of covered professional services through physicians employed by a single contracted medical group and through health care providers employed by the carrier, the carrier’s efforts to address the needs of low–income, medically underserved individuals;
(vi)
except for an access plan filed by a group model health maintenance organization, the carrier’s efforts to include local health departments in its network; and
(vii)
the carrier’s methods for assessing the health care needs of enrollees and enrollee satisfaction with health care services provided to them.
(5)
Each carrier shall monitor, on an ongoing basis, the clinical capacity of its participating providers to provide covered services to its enrollees.
(d)
(1)
On or before December 31, 2017, the Commissioner shall, in consultation with interested stakeholders, adopt regulations to establish quantitative and, if appropriate, nonquantitative criteria to evaluate the network sufficiency of health benefit plans subject to the requirements of subsection (c) of this section.
(2)
In adopting the regulations, the Commissioner may take into consideration:
(i)
geographic accessibility of primary care and specialty providers, including mental health and substance use disorder providers;
(ii)
waiting times for an appointment with participating primary care and specialty providers, including mental health and substance use disorder providers;
(iii)
primary care provider–to–enrollee ratios;
(iv)
provider–to–enrollee ratios, by specialty;
(v)
geographic variation and population dispersion;
(vi)
hours of operation;
(vii)
the ability of the network to meet the needs of enrollees, which may include:
(1)
low–income individuals;
(2)
adults and children with:
(A)
serious, chronic, or complex health conditions; or
(B)
physical or mental disabilities; and
(3)
individuals with limited English proficiency or illiteracy;
(viii)
other health care service delivery system options, including telemedicine, telehealth, mobile clinics, and centers of excellence;
(ix)
the volume of technological and specialty care services available to serve the needs of enrollees requiring technologically advanced or specialty care services;
(x)
any standards adopted by the federal Centers for Medicare and Medicaid Services or used by the Federally Facilitated Marketplace; and
(xi)
any standards adopted by another state.
(e)
(1)
On or before December 31, 2017, for a carrier that is a dental plan organization or an insurer or nonprofit health service plan that provides coverage for dental services, the Commissioner, in consultation with appropriate stakeholders, shall adopt regulations to specify the standards under subsection (b)(1)(i) of this section for dental services.
(2)
The regulations shall:
(i)
ensure that all enrollees, including adults and children, have access to providers and covered services without unreasonable delay and travel;
(ii)
ensure access to providers, including essential community providers, that serve predominantly low–income, medically underserved individuals; and
(iii)
require the carrier to specify how the carrier will monitor, on an ongoing basis, the ability of its participating providers to provide covered services to its enrollees.
(3)
In establishing the standards for dental services, the Commissioner may consider the appropriateness of quantitative and nonquantitative criteria.
(f)
A carrier that uses a provider panel:
(1)
on request, shall provide an application and information that relates to consideration for participation on the carrier’s provider panel to any provider seeking to apply for participation;
(2)
shall make publicly available its application; and
(3)
shall make efforts to increase the opportunity for a broad range of minority providers to participate on the carrier’s provider panel.
(g)
(1)
A provider that seeks to participate on a provider panel of a carrier shall submit an application to the carrier.
(2)
(i)
Subject to subparagraph (ii) of this paragraph and paragraph (3) of this subsection, the carrier, after reviewing the application, shall accept or reject the provider for participation on the carrier’s provider panel.
(ii)
A carrier may not reject a provider who provides community–based health services for a program accredited under COMAR 10.63.02 for participation on the carrier’s provider panel because the provider practices within the scope of the provider’s license and is:
(1)
a licensed master social worker, as defined in § 19–101 of the Health Occupations Article;
(2)
a licensed graduate alcohol and drug counselor, a licensed graduate marriage and family therapist, a licensed graduate professional art therapist, or a licensed graduate professional counselor, as those terms are defined in § 17–101 of the Health Occupations Article; or
(3)
a registered psychology associate, as defined in § 18–101 of the Health Occupations Article.
(iii)
If the carrier rejects the provider for participation on the carrier’s provider panel, the carrier shall send to the provider at the address listed in the application written notice of the rejection.
(3)
(i)
Subject to paragraph (4) of this subsection, within 30 days after the date a carrier receives a completed application, the carrier shall send to the provider at the address listed in the application written notice of:
(1)
the carrier’s intent to continue to process the provider’s application to obtain necessary credentialing information; or
(2)
the carrier’s rejection of the provider for participation on the carrier’s provider panel.
(ii)
The failure of a carrier to provide the notice required under subparagraph (i) of this paragraph is a violation of this article and the carrier is subject to the penalties provided by § 4–113(d) of this article.
(iii)
Except as provided in subsection (v) of this section and subparagraph (iv) of this paragraph, if, under subparagraph (i)1 of this paragraph, a carrier provides notice to the provider of its intent to continue to process the provider’s application to obtain necessary credentialing information, the carrier, within 120 days after the date the notice is provided, shall:
(1)
accept or reject the provider for participation on the carrier’s provider panel; and
(2)
send written notice of the acceptance or rejection to the provider at the address listed in the application.
(iv)
For a provider described in paragraph (2)(ii) of this subsection, if, under subparagraph (i)1 of this paragraph, a carrier provides notice to the provider of its intent to continue to process the provider’s application to obtain necessary credentialing information, within 60 days after the date a carrier receives a completed application, the carrier shall:
(1)
accept or reject the provider for participation on the carrier’s provider panel; and
(2)
send written notice of the acceptance or rejection to the provider at the address listed in the application.
(v)
The failure of a carrier to provide the notice required under subparagraph (iii)2 or (iv) of this paragraph is a violation of this article and the carrier is subject to the provisions of and penalties provided by §§ 4–113 and 4–114 of this article.
(4)
(i)
(1)
Except as provided in subsubparagraph 4 of this subparagraph, a carrier that receives a complete application shall notify the provider that the application is complete.
(2)
If a carrier does not accept applications through the online credentialing system, notice shall be given to the provider at the address listed in the application within 10 days after the date the application is received.
(3)
If a carrier accepts applications through the online credentialing system, the notice from the online credentialing system to the provider that the carrier has received the provider’s application shall be considered notice that the application is complete.
(4)
This subparagraph does not apply to a carrier that arranges a dental provider panel until the Commissioner certifies that the online credentialing system is capable of accepting the uniform credentialing form designated by the Commissioner for dental provider panels.
(ii)
(1)
A carrier that receives an incomplete application shall return the application to the provider at the address listed in the application within 10 days after the date the application is received.
(2)
The carrier shall indicate to the provider what information is needed to make the application complete.
(3)
The provider may return the completed application to the carrier.
(4)
After the carrier receives the completed application, the carrier is subject to the time periods established in paragraph (3) of this subsection.
(5)
A carrier may charge a reasonable fee for an application submitted to the carrier under this section.
(h)
A carrier may not deny an application for participation or terminate participation on its provider panel on the basis of:
(1)
sex, sexual orientation, gender identity, race, age, religion, national origin, or a protected category under the federal Americans with Disabilities Act;
(2)
the type or number of appeals that the provider files under Subtitle 10B of this title;
(3)
the number of grievances or complaints that the provider files on behalf of a patient under Subtitle 10A of this title; or
(4)
the type or number of complaints or grievances that the provider files or requests for review under the carrier’s internal review system established under subsection (l) of this section.
(i)
(1)
A carrier may not deny an application for participation or terminate participation on its provider panel solely on the basis of the license, certification, or other authorization of the provider to provide health care services if the carrier provides health care services within the provider’s lawful scope of practice.
(2)
Notwithstanding paragraph (1) of this subsection, a carrier may reject an application for participation or terminate participation on its provider panel based on the participation on the provider panel of a sufficient number of similarly qualified providers.
(3)
A violation of this subsection does not create a new cause of action.
(j)
(1)
Subject to the provisions of this subsection, a carrier may not require a provider participating on its provider panel to be recredentialed based on:
(i)
a change in the federal tax identification number of the provider;
(ii)
a change in the federal tax identification number of a provider’s employer; or
(iii)
a change in the employer of a provider, if the new employer is:
(1)
a participating provider on the carrier’s provider panel; or
(2)
the employer of providers that participate on the carrier’s provider panel.
(2)
A provider that participates on a carrier’s provider panel or the provider’s employer shall give written notice to the carrier of a change in the federal tax identification number of the provider or the provider’s employer not less than 45 days before the effective date of the change.
(3)
The notice required under paragraph (2) of this subsection shall include:
(i)
a statement of the intention of the provider or the provider’s employer to continue to provide health care services in the same field of specialization, if applicable;
(ii)
the effective date of the change in the federal tax identification number of the provider or the provider’s employer;
(iii)
the new federal tax identification number of the provider or the provider’s employer and a copy of U.S. Treasury Form W–9, or any successor or replacement form; and
(iv)
the following information about a new employer of the provider:
(1)
the employer’s name;
(2)
the name of the employer’s contact person for carrier questions about the provider; and
(3)
the address, telephone number, facsimile transmission number, and electronic mail address of the contact person for the employer.
(4)
If the new federal tax identification number or the form required to be included in the notice under paragraph (3)(iii) of this subsection is not available at the time the notice is given to a carrier, it shall be provided to the carrier promptly after it is received by the provider or the provider’s employer.
(5)
Within 30 business days after receipt of the notice required under paragraph (2) of this subsection, a carrier:
(i)
shall acknowledge receipt of the notice to the provider or the provider’s employer; and
(ii)
if the carrier considers it necessary to issue a new provider number as a result of a change in the federal tax identification number of a provider or a provider’s employer or a change in the employer of a provider, shall issue a new provider number, by mail, electronic mail, or facsimile transmission, to:
(1)
the provider or the provider’s employer; or
(2)
the representative of the provider or the provider’s employer designated in writing to the carrier.
(6)
A carrier may not terminate its existing contract with a provider or a provider’s employer based solely on a notice given to the carrier in accordance with this subsection.
(k)
A carrier may not terminate participation on its provider panel or otherwise penalize a provider for:
(1)
advocating the interests of a patient through the carrier’s internal review system established under subsection (l) of this section;
(2)
filing an appeal under Subtitle 10B of this title; or
(3)
filing a grievance or complaint on behalf of a patient under Subtitle 10A of this title.
(l)
Each carrier shall establish an internal review system to resolve grievances initiated by providers that participate on the carrier’s provider panel, including grievances involving the termination of a provider from participation on the carrier’s provider panel.
(m)
(1)
For at least 90 days after the date of the notice of termination of a primary care provider or a provider of a behavioral health care services from a carrier’s provider panel for reasons unrelated to fraud, patient abuse, incompetency, or loss of licensure status, the provider shall furnish health care services to each enrollee:
(i)
who was receiving health care services from the provider before the notice of termination; and
(ii)
who, after receiving notice under subsection (b) of this section of the termination of the provider, requests to continue receiving health care services from the provider.
(2)
A carrier shall reimburse a provider that furnishes health care services under this subsection in accordance with the provider’s agreement with the carrier.
(3)
A provider that furnishes health care services under this subsection in accordance with a provider’s agreement with a carrier shall accept as payment in full for the services payment from the carrier and cost–sharing from the patient, as applicable.
(n)
(1)
A carrier shall make the carrier’s provider directory available to prospective enrollees on the Internet and, on request of a prospective enrollee, in printed form.
(2)
The carrier’s provider directory on the Internet shall be available:
(i)
through a clear link or tab; and
(ii)
in a searchable format.
(3)
The provider directory shall include:
(i)
for each provider on the carrier’s provider panel:
(1)
the name of the provider;
(2)
the specialty areas of the provider;
(3)
whether the provider currently is accepting new patients;
(4)
for each office of the provider where the provider participates on the provider panel:
(A)
its location, including its address; and
(B)
contact information for the provider;
(5)
the gender of the provider, if the provider notifies the carrier or the multi–carrier common online provider directory information system designated under § 15–112.3 of this subtitle of the information; and
(6)
any languages spoken by the provider other than English, if the provider notifies the carrier or the multi–carrier common online provider directory information system designated under § 15–112.3 of this subtitle of the information;
(ii)
for each health care facility in the carrier’s network:
(1)
the health care facility’s name;
(2)
the health care facility’s address;
(3)
the types of services provided by the health care facility; and
(4)
contact information for the health care facility; and
(iii)
a statement that advises enrollees and prospective enrollees to contact a provider or a health care facility before seeking treatment or services, to confirm the provider’s or health care facility’s participation in the carrier’s network and the enrollee’s health benefit plan.
(o)
(1)
A carrier shall have a customer service telephone number, e–mail address link, or other electronic means by which enrollees and prospective enrollees may notify the carrier of inaccurate information in the carrier’s network directory.
(2)
If notified of a potential inaccuracy in a network directory by a person other than the provider, a carrier shall investigate the reported inaccuracy and take corrective action, if necessary, to update the network directory within 45 working days after receiving the notification.
(p)
(1)
A carrier shall notify each enrollee at the time of initial enrollment and renewal about how to access or obtain the information required under subsection (n) of this section.
(2)
(i)
(1)
Information provided in printed form under subsection (n) of this section shall be accurate on the date of publication.
(2)
A carrier shall update the information provided in printed form at least once a year.
(ii)
(1)
Information provided on the Internet under subsection (n) of this section shall be accurate on the date of initial posting and any update.
(2)
In addition to the requirement to update its provider information under subsection (t)(1) of this section, a carrier shall update the information provided on the Internet at least once every 15 days.
(3)
A carrier shall:
(i)
(1)
periodically review at least a reasonable sample size of its provider directory for accuracy; and
(2)
retain documentation of the review and make the review available to the Commissioner on request; or
(ii)
contact providers listed in the carrier’s provider directory who have not submitted a claim in the last 6 months to determine if the providers intend to remain in the carrier’s provider network.
(4)
A carrier shall demonstrate the accuracy of the information provided under paragraph (3) of this subsection on request of the Commissioner.
(5)
A carrier shall include in a provider directory that is in printed form a statement notifying a reader that:
(i)
the information contained in the provider directory is accurate as of the date of publication; and
(ii)
to obtain the most current information, the individual should consult the provider directory on the Internet or contact the carrier directly.
(6)
Before imposing a penalty against a carrier for inaccurate network directory information, the Commissioner shall take into account, in addition to any other factors required by law, whether:
(i)
the carrier afforded a provider or other person identified in § 15–112.3(c) of this subtitle an opportunity to review and update the provider’s network directory information:
(1)
through the multi–carrier common online provider directory information system designated under § 15–112.3 of this subtitle; or
(2)
directly with the carrier;
(ii)
the carrier can demonstrate the efforts made, in writing, electronically, or by telephone, to obtain updated network directory information from a provider or other person identified in § 15–112.3(c) of this subtitle;
(iii)
the carrier has contacted a provider listed in the carrier’s network directory who has not submitted a claim in the last 6 months to determine if the provider intends to remain on the carrier’s provider panel;
(iv)
the carrier includes in its network directory the last date that a provider updated the provider’s information;
(v)
the carrier has implemented any other process or procedure to:
(1)
encourage providers to update their network directory information; or
(2)
increase the accuracy of its network directory; and
(vi)
a provider or other person identified in § 15–112.3(c) of this subtitle has not updated the provider’s network directory information, despite opportunities to do so.
(q)
A policy, certificate, or other evidence of coverage shall:
(1)
indicate clearly the office in the Administration that is responsible for receiving and responding to complaints from enrollees about carriers; and
(2)
include the telephone number of the office and the procedure for filing a complaint.
(r)
The Commissioner:
(1)
shall adopt regulations that relate to the procedures that carriers must use to process applications for participation on a provider panel; and
(2)
in consultation with the Secretary of Health, shall adopt strategies to assist carriers in maximizing the opportunity for a broad range of minority providers to participate in the delivery of health care services.
(s)
A carrier may not include in a contract with a provider, ambulatory surgical facility, or hospital a term or condition that:
(1)
prohibits the provider, ambulatory surgical facility, or hospital from offering to provide services to the enrollees of another carrier at a lower rate of reimbursement;
(2)
requires the provider, ambulatory surgical facility, or hospital to provide the carrier with the same reimbursement arrangement that the provider, ambulatory surgical facility, or hospital has with another carrier if the reimbursement arrangement with the other carrier is for a lower rate of reimbursement; or
(3)
requires the provider, ambulatory surgical facility, or hospital to certify to the carrier that the reimbursement rate being paid by the carrier to the provider, ambulatory surgical facility, or hospital is not higher than the reimbursement rate being received by the provider, ambulatory surgical facility, or hospital from another carrier.
(t)
(1)
(i)
Subject to subparagraph (ii) of this paragraph, a carrier shall update the information that must be made available on the Internet under subsection (n) of this section within 2 working days after receipt of electronic notification or notification by first–class mail tracking method from the participating provider of a change in the applicable information.
(ii)
A dental carrier shall update the information required by this subsection within 15 working days after receipt of the notification described in subparagraph (i) of this paragraph.
(2)
Notification is presumed to have been received by a carrier:
(i)
3 working days after the date the participating provider placed the notification in the U.S. mail, if the participating provider maintains the stamped certificate of mailing for the notice; or
(ii)
on the date recorded by the courier, if the notification was delivered by courier.
(u)
(1)
A carrier may not require a provider that provides health care services through a group practice or health care facility that participates on the carrier’s provider panel under a contract with the carrier to be considered a participating provider or accept the reimbursement fee schedule applicable under the contract when:
(i)
providing health care services to enrollees of the carrier through an individual or group practice or health care facility that does not have a contract with the carrier; and
(ii)
billing for health care services provided to enrollees of the carrier using a different federal tax identification number than that used by the group practice or health care facility under a contract with the carrier.
(2)
A nonparticipating provider shall notify an enrollee:
(i)
that the provider does not participate on the provider panel of the enrollee’s carrier; and
(ii)
of the anticipated total charges for the health care services.
(v)
The provisions of subsection (g)(3)(iii) of this section do not apply to a carrier that uses a credentialing intermediary that:
(1)
is a hospital or academic medical center;
(2)
is a participating provider on the carrier’s provider panel; and
(3)
acts as a credentialing intermediary for that carrier for health care practitioners that:
(i)
participate on the carrier’s provider panel; and
(ii)
have privileges at the hospital or academic medical center.
(w)
(1)
Notwithstanding subsection (u)(1) of this section, a carrier shall reimburse a group practice on the carrier’s provider panel at the participating provider rate for covered services provided by a provider who is not a participating provider if:
(i)
the provider is employed by or a member of the group practice;
(ii)
the provider has applied for acceptance on the carrier’s provider panel and the carrier has notified the provider of the carrier’s intent to continue to process the provider’s application to obtain necessary credentialing information;
(iii)
the provider has a valid license issued by a health occupations board to practice in the State; and
(iv)
the provider:
(1)
is currently credentialed by an accredited hospital in the State; or
(2)
has professional liability insurance.
(2)
A carrier shall reimburse a group practice on the carrier’s provider panel in accordance with paragraph (1) of this subsection from the date the notice required under subsection (g)(3)(i)1 of this section is sent to the provider until the date the notice required under subsection (g)(3)(iii)2 of this section is sent to the provider.
(3)
A carrier that sends written notice of rejection of a provider for credentialing under subsection (g)(3)(iii)2 of this section shall reimburse the provider as a nonparticipating provider for covered services provided on or after the date the notice is sent.
(4)
A health maintenance organization may not deny payment to a provider under this subsection solely because the provider was not a participating provider at the time the services were provided to an enrollee.
(5)
A provider who is not a participating provider of a carrier and whose group practice is eligible for reimbursement under paragraph (1) of this subsection may not hold an enrollee of the carrier liable for the cost of any covered services provided to the enrollee during the time period described in paragraph (2) of this subsection, except for any deductible, copayment, or coinsurance amount owed by the enrollee to the group practice or provider under the terms of the enrollee’s contract or certificate.
(6)
A group practice shall disclose in writing to an enrollee at the time services are provided that:
(i)
the treating provider is not a participating provider;
(ii)
the treating provider has applied to become a participating provider;
(iii)
the carrier has not completed its assessment of the qualifications of the treating provider to provide services as a participating provider; and
(iv)
any covered services received must be reimbursed by the carrier at the participating provider rate.
(x)
A carrier may not impose a limit on the number of behavioral health providers at a health care facility that may be credentialed to participate on a provider panel.
(y)
(1)
In this subsection, “health system” means:
(i)
a hospital and any entity affiliated with the hospital through ownership, governance, membership, or other means; or
(ii)
a parent corporation of one or more hospitals and any entity affiliated with the parent corporation through ownership, governance, membership, or other means.
(2)
A carrier and a health system shall provide to each other written notice of any intent to terminate a contract between the carrier and the health system:
(i)
at least 90 days before the proposed date of the termination of the contract; or
(ii)
in the case of nonrenewal, at least 90 days before the end of the contract period.
(3)
(i)
For each contract between a carrier and a health system that is entered into, renewed, amended, or continued on or after October 1, 2026, if the contract is not renewed or is terminated by the carrier or the health system, the carrier and the health system shall continue to adhere to the terms of the contract, including reimbursement terms and patient balance billing protections for all health care services provided under the contract, for a period of:
(1)
at least 90 days after the date of termination; or
(2)
in the case of a nonrenewal, at least 90 days after the end of the contract period.
(ii)
Except as otherwise agreed to by a carrier and a health system, the reimbursement terms of a contract entered into by the carrier and the health system during the 90–day period shall be retroactive to:
(1)
the date of termination; or
(2)
in the case of a nonrenewal, the end date of the contract period.
(iii)
This paragraph does not apply if the carrier and health system:
(1)
agree, in writing, to the termination or nonrenewal of the contract; and
(2)
provide the notices required under paragraph (2) of this subsection.
(4)
The Commissioner shall develop a uniform form that carriers, providers, and health care systems shall use for requests to continue to receive health services in accordance with subsection (b) of this section or 42 U.S.C. § 300GG–113.
Md. Code Ann., Ins. § 15-112.1 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–112.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Carrier” means:
(1)
an insurer;
(2)
a nonprofit health service plan;
(3)
a health maintenance organization;
(4)
a dental plan organization;
(5)
a managed care organization; or
(6)
any other person that provides health benefit plans subject to regulation by the State.
(ii)
“Carrier” includes an entity that arranges a provider panel for a carrier.
(3)
“Credentialing intermediary” means a person to whom a carrier has delegated credentialing or recredentialing authority and responsibility.
(4)
“Health care provider” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.
(5)
“Provider panel” means the providers that contract with a carrier to provide health care services to the enrollees under a health benefit plan of the carrier.
(6)
“Uniform credentialing form” means the form designated by the Commissioner for use by a carrier or its credentialing intermediary for credentialing and recredentialing a health care provider for participation on a provider panel.
(b)
(1)
Except as provided in subsection (c) of this section, a carrier or its credentialing intermediary shall accept the uniform credentialing form as the sole application for a health care provider to become credentialed or recredentialed for a provider panel of the carrier.
(2)
A carrier or its credentialing intermediary shall make the uniform credentialing form available to any health care provider that is to be credentialed or recredentialed by that carrier or credentialing intermediary.
(c)
The requirements of subsection (b) of this section do not apply to a hospital or academic medical center that:
(1)
is a participating provider on the carrier’s provider panel; and
(2)
acts as a credentialing intermediary for that carrier for health care practitioners that:
(i)
participate on the carrier’s provider panel; and
(ii)
have privileges at the hospital or academic medical center.
(d)
The Commissioner may impose a penalty not to exceed $500 against any carrier for each violation of this section by the carrier or its credentialing intermediary.
(e)
(1)
The Commissioner may adopt regulations to implement the provisions of this section.
(2)
The Commissioner may designate a provider credentialing application developed by a nonprofit alliance of health plans and trade associations for an online credentialing system offered to carriers and providers as the uniform credentialing form if:
(i)
the provider credentialing application is available to providers at no charge; and
(ii)
use of the provider credentialing application is not conditioned on submitting the provider credentialing application to a carrier through the online credentialing system.
Md. Code Ann., Ins. § 15-112.2 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–112.2LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Capitated dental provider panel” means a provider panel for one or more dental plan organizations offering contracts only for dental services reimbursed on a capitated basis for certain services.
(3)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization; or
(iv)
a dental plan organization.
(4)
“Enrollee” means a person entitled to health care benefits from a carrier.
(5)
“Fee–for–service dental provider panel” means a provider panel for one or more dental plan organizations, insurers, or nonprofit health service plans offering contracts only for dental services reimbursed on a full or discounted fee–for–service basis.
(6)
“HMO provider panel” means a provider panel for one or more health maintenance organizations.
(7)
“Managed care organization” has the meaning stated in § 15–101 of the Health – General Article.
(8)
“Non–HMO provider panel” means a provider panel for one or more nonprofit health service plans or insurers.
(9)
“Provider” has the meaning stated in § 19–701 of the Health – General Article.
(10)
“Provider contract” means a contract:
(i)
between a provider and a carrier, an affiliate of a carrier, or an entity that contracts with a provider to serve a carrier; and
(ii)
under which the provider agrees to provide health care services to enrollees.
(11)
“Provider panel” means the providers that contract either directly or through a subcontracting entity with a carrier to provide health care services to enrollees.
(b)
(1)
A provider contract may not contain a provision that requires a provider:
(i)
as a condition of participating in a non–HMO provider panel, to participate in an HMO provider panel; or
(ii)
as a condition of participating in a fee–for–service dental provider panel, to participate in a capitated dental provider panel.
(2)
Notwithstanding paragraph (1) of this subsection, a provider contract may contain a provision that requires a provider, as a condition of participating in a non–HMO provider panel, an HMO provider panel, or a dental provider panel, to participate in a managed care organization.
(c)
(1)
This subsection does not apply to a provider contract for a dental provider panel.
(2)
Each provider contract shall disclose the carriers comprising each provider panel.
(d)
(1)
This subsection does not apply to a provider contract for a dental provider panel.
(2)
If a provider contract includes more than one schedule of applicable fees, the provider contract may not contain a provision that requires a provider as a condition of participation to accept each schedule of applicable fees included in the provider contract.
(3)
If a provider rejects a schedule of applicable fees, the provider contract may not require the provider to treat the enrollees of the carriers that reimburse the provider in accordance with any of the rejected schedules of applicable fees.
(4)
Notwithstanding the provisions of paragraph (1) of this subsection, a provider contract may include a provision that requires a provider, as a condition of participation, to accept each schedule of applicable fees for a carrier that is not affiliated through common ownership with the entity arranging the provider panel.
(e)
If a provider elects to terminate participation on a provider panel, the provider shall:
(1)
notify the carrier at least 90 days before the date of termination; and
(2)
for at least 90 days after the date of the notice of termination, continue to furnish health care services to an enrollee of the carrier for whom the provider was responsible for the delivery of health care services before the notice of termination.
(f)
A provider contract may not contain a provision that requires a participating dental provider, as a condition of continued participation in a capitated dental provider panel or a fee–for–service dental provider panel, to accept an added, revised, or amended fee schedule that contains a lower fee.
(g)
(1)
In this subsection, “covered services” means health care services that are reimbursable under a policy or contract for dental services between an enrollee and a carrier, subject to any contractual limitations on benefits, including deductibles, copayments, or frequency limitations.
(2)
A carrier may not include in a dental provider contract a provision that requires a dental provider to provide health care services that are not covered services at a fee set by the carrier.
(h)
(1)
In this subsection, “covered services” means health care services that are reimbursable under a policy or contract for vision services between an enrollee and a carrier, subject to any contractual limitations on benefits, including deductibles, copayments, or frequency limitations.
(2)
A carrier may not include in a vision provider contract a provision that requires a vision provider:
(i)
to provide health care services that are not covered services at a fee set by the carrier; or
(ii)
to provide discounts on materials that are not covered benefits.
(3)
(i)
A carrier may not include in a vision provider contract a provision that requires a vision provider, as a condition of participation in a fee–for–service vision provider panel, to participate in a capitated vision provider panel.
(ii)
Notwithstanding subparagraph (i) of this paragraph, a vision provider contract may contain a provision that requires a vision provider, as a condition of participating in a non–HMO vision provider panel or an HMO vision provider panel to participate in a managed care organization.
Md. Code Ann., Ins. § 15-112.3 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–112.3LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Carrier” has the meaning stated in § 15–112 of this subtitle.
(ii)
“Carrier” does not include a managed care organization, as defined in Title 15, Subtitle 1 of the Health – General Article.
(3)
“Multi–carrier common online provider directory information system” means the system designated by the Commissioner for use by providers to provide and update their provider directory information with carriers.
(b)
The Commissioner may designate a multi–carrier common online provider directory information system developed by a nonprofit alliance of health plans and trade associations if:
(1)
the system is available to providers nationally;
(2)
the system is available to providers at no charge;
(3)
the system allows providers to:
(i)
attest online to the accuracy of their information; and
(ii)
(1)
correct any inaccurate information; and
(2)
attest to the correction; and
(4)
the nonprofit alliance has a well–established mechanism for outreach to providers.
(c)
A carrier shall accept new and updated provider directory information for a provider submitted:
(1)
(i)
through the multi–carrier common online provider directory information system; or
(ii)
directly to the carrier; and
(2)
from:
(i)
the provider;
(ii)
a hospital or academic medical center that:
(1)
is a participating provider on the carrier’s provider panel; and
(2)
acts as a credentialing intermediary for the carrier for providers that:
(A)
participate on the carrier’s provider panel; and
(B)
have privileges at the hospital or academic medical center; or
(iii)
any other person that performs credentialing functions on behalf of a provider.
Md. Code Ann., Ins. § 15-113 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–113LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization; or
(v)
any other person that provides health benefit plans subject to regulation by the State.
(3)
“Eligible provider” means:
(i)
a licensed physician, as defined in § 14–101 of the Health Occupations Article, who voluntarily participates in a two–sided incentive arrangement; or
(ii)
a set of health care practitioners that voluntarily participate in a two–sided incentive arrangement.
(4)
“Health care practitioner” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.
(5)
“Set of health care practitioners” means:
(i)
a group practice;
(ii)
a clinically integrated organization established in accordance with Subtitle 19 of this title;
(iii)
an accountable care organization established in accordance with 42 U.S.C. § 1395jjj and any applicable federal regulations; or
(iv)
a clinically integrated network that is a provider entity that meets the criteria established in guidance issued by the Federal Trade Commission, including a network of behavioral health care programs licensed under § 7.5–401 of the Health – General Article.
(6)
“Two–sided incentive arrangement” means an arrangement between an eligible provider and a carrier in which the eligible provider may earn an incentive and a carrier may recoup funds from the eligible provider in accordance with the terms of a contract entered into with the eligible provider that meets the requirements of this section.
(b)
A carrier may not reimburse a health care practitioner in an amount less than the sum or rate negotiated in the carrier’s provider contract with the health care practitioner.
(c)
(1)
This section does not prohibit a carrier from:
(i)
providing bonuses or other incentive–based compensation to a health care practitioner or a set of health care practitioners; or
(ii)
entering into a two–sided incentive arrangement with an eligible provider.
(2)
A bonus or other incentive–based compensation program or two–sided incentive arrangement authorized under this section:
(i)
may not create a disincentive to the provision of medically appropriate or medically necessary health care services; and
(ii)
if the carrier is a health maintenance organization, shall comply with the provisions of § 19–705.1 of the Health – General Article.
(3)
A bonus or other incentive–based compensation or two–sided incentive arrangement authorized under this section:
(i)
if applicable, shall promote health equity, improvement of health care outcomes, and the provision of preventive health care services; or
(ii)
may reward a health care practitioner, a set of health care practitioners, or an eligible provider, based on satisfaction of performance measures, if the following is agreed on in writing by the carrier and the health care practitioner, set of health care practitioners, or eligible provider:
(1)
the performance measures, including the source of the measures;
(2)
the method and the time period for calculating whether the performance measures have been satisfied;
(3)
the method by which the health care practitioner, set of health care practitioners, or eligible provider may request reconsideration of the calculations by the carrier; and
(4)
if applicable, the risk–adjustment method used.
(4)
Acceptance of a bonus or other incentive–based compensation or two–sided incentive arrangement under this subsection shall be voluntary.
(5)
A carrier may not reduce the fee schedule of a health care practitioner or a set of health care practitioners because the health care practitioner or set of health care practitioners does not participate in the carrier’s bonus or other incentive–based compensation or two–sided incentive arrangement program.
(6)
Participation in a two–sided incentive arrangement may not be the sole opportunity for a health care practitioner or a set of health care practitioners to be eligible to receive increases in reimbursement.
(7)
A carrier may not require as a condition of participation in the carrier’s provider network:
(i)
a health care practitioner or set of health care practitioners to participate in the carrier’s bonus or other incentive–based compensation program; or
(ii)
an eligible provider to participate in the carrier’s two–sided incentive arrangement program.
(8)
A health care practitioner, a set of health care practitioners, an eligible provider, a health care practitioner’s designee, a designee of a set of health care practitioners, or a designee of an eligible provider may file a complaint with the Administration regarding a violation of this subsection.
(d)
(1)
A carrier shall provide a health care practitioner, a set of health care practitioners, or an eligible provider with a copy of:
(i)
a schedule of all applicable fees or the 50 most common services billed by a health care practitioner in that specialty, whichever is less;
(ii)
a description of the coding guidelines used by the carrier that are applicable to the services billed by a health care practitioner in that specialty;
(iii)
the information about the practitioner and the methodology that the carrier uses to determine whether to:
(1)
increase or reduce the practitioner’s level of reimbursement;
(2)
provide a bonus or other incentive–based compensation to the practitioner; and
(3)
recoup compensation from an eligible provider under a two–sided incentive arrangement; and
(iv)
a summary of the terms of a two–sided incentive arrangement program.
(2)
Except as provided in paragraph (4) of this subsection, a carrier shall provide the information required under paragraph (1) of this subsection in the manner indicated in each of the following instances:
(i)
in writing before a contract execution;
(ii)
in writing or electronically 30 days before a change; and
(iii)
in writing or electronically on request of the health care practitioner, set of health care practitioners, or eligible provider.
(3)
Except as provided in paragraph (4) of this subsection, a carrier shall make the pharmaceutical formulary that the carrier uses available to a health care practitioner, a set of health care practitioners, or an eligible provider electronically.
(4)
On written request of a health care practitioner, a set of health care practitioners, or an eligible provider, a carrier shall provide the information required under paragraphs (1) and (3) of this subsection in writing.
(5)
The Administration may adopt regulations to carry out the provisions of this subsection.
(e)
(1)
A carrier that compensates health care practitioners or a set of health care practitioners wholly or partly on a capitated basis in accordance with § 15–2102 of this article may not retain any capitated fee attributable to an enrollee or covered person during an enrollee’s or covered person’s contract year.
(2)
A carrier is in compliance with paragraph (1) of this subsection if, within 45 days after an enrollee or covered person chooses or obtains health care from a health care practitioner or a set of health care practitioners, the carrier pays to the health care practitioner or set of health care practitioners all accrued but unpaid capitated fees attributable to that enrollee or person that the health care practitioner or set of health care practitioners would have received had the enrollee or person chosen the health care practitioner or set of health care practitioners at the beginning of the enrollee’s or covered person’s contract year.
(3)
Acceptance of a capitated payment shall be voluntary.
(f)
(1)
Under a two–sided incentive arrangement that complies with the requirements of this section, a carrier may recoup funds paid to an eligible provider based on the terms of a written contract between the carrier and the eligible provider that at a minimum:
(i)
establish a target budget for:
(1)
the total cost of care of a population of patients adjusted for risk and population size; or
(2)
the cost of an episode of care;
(ii)
limit recoupment to not more than 50% of the excess above the mutually agreed on target established in accordance with item (i) of this paragraph;
(iii)
specify a mutually agreed on maximum liability for total recoupment that may not exceed 10% of the annual payments from the carrier to the eligible provider;
(iv)
provide an opportunity for gains by an eligible provider that is greater than the opportunity for recoupment by the carrier;
(v)
following good faith negotiations, provide an opportunity for an audit by an independent third party and an independent third–party dispute resolution process;
(vi)
require the carrier and the eligible provider to negotiate in good faith adjustments to the target budget when:
(1)
certain circumstances beyond the control of the carrier or the eligible provider arise, including changes in hospital rates; and
(2)
material changes occur in health care economics, health care delivery, or regulations that impact the arrangement; and
(vii)
require the carrier to pay any incentive to or request any recoupment from the eligible provider within 6 months after the end of the contract year, unless the carrier or eligible provider initiates a dispute relating to the recoupment or incentive amount.
(2)
Unless mutually agreed to by an eligible provider and a carrier, an arrangement entered into under this subsection may not provide an opportunity for recoupment by the carrier based on the eligible provider’s performance during the first 12 months of the arrangement.
(3)
A carrier that enters into a two–sided incentive arrangement with an eligible provider in which the amount of any payment is determined, in whole or in part, on the total cost of care of a population of patients or an episode of care, shall, at least quarterly, disclose to the eligible provider the following information in a manner that meets federal and State data use and privacy standards:
(i)
any amount paid to another health care provider that is included in the total cost of care of a patient in the population or episode of care; and
(ii)
any copayment, coinsurance, or deductible that is included in the total cost of care of a patient in the population or episode of care.
(4)
Unless mutually agreed to by the carrier and eligible provider, a two–sided incentive arrangement may not be amended during the term of the contract.
(5)
The opportunity for independent third–party dispute resolution provided for in paragraph (1)(v) of this subsection may not be required to be exhausted before a member or member’s representative is allowed to file an appeal of a coverage decision under § 15–10D–02 of this title.
(6)
Nothing in this subsection may be construed to:
(i)
alter any requirement for a carrier to pay a hospital or related institution the rate approved by the Health Services Cost Review Commission for hospital services; or
(ii)
supersede the Health Services Cost Review Commission’s jurisdiction or authority over rate review and approval for hospital services.
Md. Code Ann., Ins. § 15-114 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–114LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization; or
(v)
any other person that provides dental benefit plans subject to regulation by the State.
(3)
“Dental point–of–service option” means a delivery system that allows an insured, enrollee, or other covered person under a dental benefit plan to receive dental services outside a provider panel.
(4)
“Provider panel” means the providers that contract with a carrier to provide dental services to the carrier’s insureds, enrollees, or other covered persons under the carrier’s dental benefit plan.
(b)
(1)
If an employer, association, or other private group arrangement offers dental benefit plan coverage to employees or other individuals only through a carrier’s provider panel, the carrier of the employer, association, or other private group arrangement shall offer, or contract with another carrier to offer, a dental point–of–service option to the employer, association, or other private group arrangement as an additional benefit for an employee or other individual, to accept or reject at the employee’s or other individual’s option.
(2)
If a carrier’s dental provider panel is the sole delivery system offered to employees by an employer, the carrier:
(i)
shall offer the employer a dental point–of–service option for the individual employee to accept or reject;
(ii)
may not impose a minimum participation level on the dental point–of–service option; and
(iii)
as part of the group enrollment application, shall provide to each employer a disclosure statement for each dental point–of–service option offered that conforms to regulations, for the point–of–service option required under § 19–710.2 of the Health – General Article, adopted by:
(1)
the Maryland Health Care Commission for the small group market; and
(2)
the Administration for the non–small group market.
(c)
(1)
An employer, association, or other private group arrangement may require an employee or other individual who accepts the additional coverage under a dental point–of–service option under subsection (b) of this section to pay a premium over the amount of the premium for the dental benefit coverage offered by the carrier only through its provider panel.
(2)
A carrier may impose different cost–sharing provisions for the dental point–of–service option based on whether the dental service is provided through the carrier’s provider panel or outside the carrier’s provider panel.
Md. Code Ann., Ins. § 15-115 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–115LinkCopy Citation
(a)
(1)
In this section, “carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization; or
(v)
any other person that provides health benefit plans subject to regulation by the State.
(2)
“Carrier” includes an entity that arranges a provider panel for a carrier.
(b)
A carrier that operates a managed care organization under Title 15, Subtitle 1 of the Health - General Article may not deny, limit, or otherwise impair the participation of a provider under contract with the carrier for choosing not to participate or limiting participation in the carrier’s managed care organization if the carrier is in violation of § 15-102.5 of the Health - General Article.
Md. Code Ann., Ins. § 15-116 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–116LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization; or
(v)
any other person that provides health benefit plans subject to regulation by the State.
(3)
“Health care provider” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.
(b)
A carrier, as a condition of a contract with a health care provider or in any other manner, may not prohibit a health care provider from discussing with or communicating to an enrollee, subscriber, public official, or other person information that is necessary or appropriate for the delivery of health care services, including:
(1)
communications that relate to treatment alternatives;
(2)
communications that are necessary or appropriate to maintain the provider-patient relationship while the patient is under the health care provider’s care;
(3)
communications that relate to an enrollee’s or subscriber’s right to appeal a coverage determination of a carrier with which the health care provider, enrollee, or subscriber does not agree; and
(4)
opinions and the basis of an opinion about public policy issues.
(c)
This section does not prohibit a carrier, as a condition of a contract between the carrier and a health care provider, from prohibiting tortious interference with a contract as recognized under State law.
Md. Code Ann., Ins. § 15-117 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–117LinkCopy Citation
(a)
This section applies to insurers and nonprofit health service plans that issue or deliver individual hospital or major medical insurance policies or group or blanket health insurance policies in the State.
(b)
An entity subject to this section, by contract or in any other manner, may not require a health care provider to indemnify the entity or hold the entity harmless from a coverage decision or negligent act of the entity.
Md. Code Ann., Ins. § 15-118 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–118LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Health care service” means a health or medical care procedure or service rendered by a provider that:
(i)
provides testing, diagnosis, or treatment of human disease or dysfunction; or
(ii)
dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of human disease or dysfunction.
(3)
“Provider” means a physician, hospital, or other person that is licensed or otherwise authorized to provide health care services.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide coverage for health care services to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide coverage for health care services to individuals or groups under contracts that are issued or delivered in the State.
(c)
If an entity subject to this section negotiates and enters into a contract with providers to render health care services to insureds, subscribers, or members at alternative rates of payment, and coinsurance payments are to be based on a percentage of the fee for health care services rendered by a provider, the entity shall calculate the amount of the coinsurance payment to be paid by the insured, subscriber, or member exclusively from the negotiated alternative rate for the health care service rendered.
(d)
An entity subject to this section may not charge or collect from an insured, a subscriber, or a member a coinsurance payment amount that is greater than the amount calculated under subsection (c) of this section.
Md. Code Ann., Ins. § 15-118.1 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–118.1LinkCopy Citation
Md. Code Ann., Ins. § 15-119 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–119LinkCopy Citation
(a)
This section applies to insurers and nonprofit health service plans that issue or deliver individual, group, or blanket health insurance policies in the State.
(b)
An entity subject to this section that requires insureds to have a written referral to receive consultation services shall use the uniform consultation referral form adopted by the Commissioner under § 15–120 of this subtitle as the sole instrument for referrals for consultation services.
(c)
An entity subject to this section may not impose as a condition of coverage a requirement to:
(1)
modify the uniform consultation referral form; or
(2)
submit additional consultation referral forms.
(d)
The uniform consultation referral form:
(1)
shall be properly completed by the health care provider that refers the insured for consultation services; and
(2)
may be transmitted electronically.
Md. Code Ann., Ins. § 15-120 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–120LinkCopy Citation
(a)
Subject to subsection (b) of this section, the Commissioner shall adopt by regulation a uniform consultation referral form for use by insurers, nonprofit health service plans, and health maintenance organizations that require insureds or subscribers to have a written referral to receive consultation services.
(b)
The Commissioner may waive the requirements of regulations adopted under subsection (a) of this section for the use of uniform consultation referral forms for an entity that uses the forms solely for internal purposes.
(c)
The Commissioner, in consultation with the Maryland Health Care Commission, shall adopt by regulation standards for the electronic transmission of the data elements contained in the uniform consultation referral form.
Md. Code Ann., Ins. § 15-121 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–121LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization;
(v)
any person or entity acting as a third party administrator; or
(vi)
except for a managed care organization as defined in Title 15, Subtitle 1 of the Health – General Article, any other person that provides health benefit plans subject to regulation by the State.
(3)
“Contract” means any written agreement between a provider and a carrier for the provider to render health care services to enrollees of the carrier.
(4)
“Enrollee” means any person or subscriber entitled to health care benefits from a carrier.
(5)
“Health care services” means a health or medical care procedure or service rendered by a provider that:
(i)
provides testing, diagnosis, or treatment of a human disease or dysfunction; or
(ii)
dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction.
(6)
(i)
“Provider” means a person or entity licensed, certified, or otherwise authorized under the Health Occupations Article or the Health – General Article to provide health care services.
(ii)
“Provider” includes:
(1)
a health care facility;
(2)
a pharmacy;
(3)
a professional services corporation;
(4)
a partnership;
(5)
a limited liability company;
(6)
a professional office; and
(7)
any other entity licensed or authorized by law to provide or deliver professional health care services through or on behalf of a provider.
(b)
This section applies to a carrier that provides health care services to enrollees, or otherwise makes health care services available to enrollees, through contracts with providers.
(c)
(1)
Each carrier shall identify and disclose in layman’s terms in its enrollment sales materials the reimbursement methodology or methodologies the carrier uses to reimburse physicians for health care services rendered to enrollees, including capitation, case rates, discounted fee-for-service, and fee-for-service reimbursement methodologies.
(2)
The Maryland Health Care Commission shall develop a uniform definition in layman’s terms of each reimbursement methodology required to be disclosed and identified by carriers under paragraph (1) of this subsection, including a representative example of a typical capitation arrangement between a carrier and a physician.
(d)
(1)
In addition to the requirements of subsection (c)(1) of this section, each carrier shall disclose in its enrollment sales materials the distribution of each $100 it receives in premium dollars from enrollees for the preceding calendar year, for which data are available.
(2)
The disclosure required under paragraph (1) of this subsection shall be in the form of a pie chart or bar graph with descriptive terms and in layman’s terms that identifies consistent with the National Association of Insurance Commissioners’ health maintenance organization annual statement (“orange form”):
(i)
the proportion of every $100 in premium dollars that the carrier uses to pay providers for the direct provision of health care services to enrollees, including what proportion is for direct medical care expenses; and
(ii)
the proportion of every $100 in premium dollars that the carrier uses to pay for plan administration.
Md. Code Ann., Ins. § 15-122 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–122LinkCopy Citation
(a)
In this section, “carrier” means:
(1)
an insurer;
(2)
a nonprofit health service plan;
(3)
a health maintenance organization;
(4)
a dental plan organization; or
(5)
any other person that provides health benefit plans subject to regulation by the State.
(b)
Before renewing a health benefit plan, a carrier shall mail a notice of renewal to the group contract holder at least 45 days before the expiration of the health benefit plan.
(c)
The notice of renewal shall include the dates of the renewal period, the health benefit plan rates, and the terms of coverage under the health benefit plan.
Md. Code Ann., Ins. § 15-122.1 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–122.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Advance directive” has the meaning stated in § 5–601 of the Health – General Article.
(3)
(i)
“Carrier” means:
(1)
an insurer;
(2)
a nonprofit health service plan;
(3)
a health maintenance organization; and
(4)
any other person that provides health benefit plans subject to regulation by the State.
(ii)
“Carrier” does not include a managed care organization.
(b)
A carrier shall provide the advance directive information sheet developed under § 5–615 of the Health – General Article:
(1)
to all members or enrollees in initial enrollment materials distributed after initial purchase and upon renewal and in the carrier’s member publications;
(2)
if the carrier maintains a website, on the carrier’s website; and
(3)
at the request of a member.
(c)
If a carrier maintains a website, after the tab on the State–designated health information exchange website required under § 19–145(b)(2)(iv) of the Health – General Article is developed, the carrier shall provide a link to the webpage that is accessed through the tab.
(d)
This section may not be construed to require a carrier to:
(1)
assist a member or enrollee in drafting an electronic advance care planning document;
(2)
store electronic advance care planning documents; or
(3)
access advance care planning documents.
Md. Code Ann., Ins. § 15-123 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–123LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization;
(v)
any person or entity acting as a third party administrator; or
(vi)
except for a managed care organization as defined in Title 15, Subtitle 1 of the Health – General Article, any other person that provides health benefit plans subject to regulation by the State.
(3)
“Contract” means any written agreement between a provider and a carrier for the provider to render health care services to enrollees of the carrier.
(4)
“Diagnostic services” means any medical or surgical service or procedure that allows a provider to identify or diagnose a human disease or disorder.
(5)
“Enrollee” means any person or subscriber entitled to health care benefits from a carrier.
(6)
“Health care services” means a health or medical care procedure or service rendered by a provider that:
(i)
provides testing, diagnosis, or treatment of a human disease or dysfunction; or
(ii)
dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction.
(7)
(i)
“Provider” means a person or entity licensed, certified, or otherwise authorized under the Health Occupations Article or the Health – General Article to provide health care services.
(ii)
“Provider” includes:
(1)
a health care facility;
(2)
a pharmacy;
(3)
a professional services corporation;
(4)
a partnership;
(5)
a limited liability company;
(6)
a professional office; and
(7)
any other entity licensed or authorized by law to provide or deliver professional health care services through or on behalf of a provider.
(8)
“Therapeutic services” means any medical or surgical service or procedure that a provider can use to treat a human disease or disorder.
(b)
This section applies to any carrier that provides health care services to enrollees or otherwise makes health care services available to enrollees through contracts with providers.
(c)
The section does not:
(1)
apply to any cosmetic or medically unnecessary service or procedure that typically would be excluded from coverage by any carrier that issues or delivers contracts or policies of health insurance in the State; or
(2)
affect the right of an enrollee to appeal any adverse decision by a carrier through the carrier’s appeal process.
(d)
(1)
Each carrier shall disclose to providers and enrollees the carrier’s definition of “experimental medical care”.
(2)
The carrier shall disclose the definition in:
(i)
contracts offered to providers that may render direct health care services to the enrollees of the carrier; and
(ii)
marketing materials and enrollment materials of the carrier that are provided to current enrollees and prospective enrollees, as appropriate.
(e)
Each carrier shall establish or subscribe or contract to provide a systematic, scientific process to follow for evaluating emerging medical and surgical treatments to ensure that subscribers have access to the latest appropriate treatments.
(f)
The process established or subscribed to or contracted for by a carrier under subsection (e) of this section shall include:
(1)
a comprehensive review of medical literature and data evaluation; and
(2)
input from physicians and other recognized experts:
(i)
who are not employees of the carrier; and
(ii)
who:
(1)
are currently treating patients for the disease or condition being evaluated;
(2)
are board certified in the pertinent specialty or subspecialty area of the disease or condition being evaluated;
(3)
are generally recognized by their peers to be authoritative resources in the clinical area being evaluated as evidenced by:
(A)
faculty appointments;
(B)
authorship of a significant body of peer–reviewed clinical literature in the pertinent specialty or subspecialty area; or
(C)
a demonstrated history of leadership in local, State, or national professional associations and nonprofit patient and community advocacy organizations that address the disease or condition and the specialty or subspecialty area in question; or
(4)
have a demonstrated history of substantial experience and practical knowledge in the specialty or subspecialty area in question.
(g)
A carrier’s decision to provide coverage for an emerging medical or surgical treatment shall result from the consensus of opinion from its own analysis and the knowledge provided to the carrier from the process identified by the carrier in subsection (f) of this section.
(h)
Each carrier, in conjunction with the clinical experts identified by the carrier under subsection (f)(2) of this section, shall decide the patient selection criteria for an emerging medical or surgical treatment for which coverage by the carrier is to be provided.
(i)
Each carrier shall provide a description of the process identified by the carrier under subsection (f) of this section to enrollees and contracting providers and all other providers on request.
(j)
(1)
A carrier’s coverage decision on an emerging medical or surgical treatment shall be in compliance with § 15–10B–07 of this title, when being appealed by an enrollee.
(2)
A carrier may reevaluate annually whether scientific advances warrant a change in the carrier’s coverage and payment policy for an emerging medical or surgical treatment.
(k)
After notifying a carrier and providing an opportunity for a hearing, the Commissioner may issue an order under § 4–113(d) of this article for a violation of this section.
(l)
(1)
The Commissioner may waive the application of subsection (f) of this section for a carrier that has in place a process for evaluating emerging medical and surgical treatments used for the purpose of making coverage decisions, if the Commissioner determines that the carrier’s process is substantially equivalent to, or exceeds, the requirements of this section.
(2)
A carrier receiving a waiver under paragraph (1) of this subsection shall report any change in its process for evaluating emerging medical and surgical treatments to the Commissioner.
(3)
The Commissioner may withdraw a waiver granted under paragraph (1) of this subsection whenever the Commissioner determines that the carrier’s process for evaluating emerging medical and surgical treatments is not substantially equivalent to the requirements of this section.
(m)
The Commissioner may adopt regulations to carry out this section.
Md. Code Ann., Ins. § 15-124 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–124LinkCopy Citation
(a)
In this section, “group health insurance” has the meaning stated in § 15–301 of this title.
(b)
This section applies to insurers and nonprofit health service plans that issue or deliver group health insurance policies in the State.
(c)
An entity subject to this section when issuing or renewing a group health insurance policy with an employer that does not include dependent coverage shall provide enrollment information to insured employees regarding the methods of enrolling any dependent of an insured employee in the Maryland Children’s Health Program established under § 15-301 of the Health - General Article.
Md. Code Ann., Ins. § 15-125 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–125LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Carrier” means:
(1)
an insurer;
(2)
a nonprofit health service plan;
(3)
a health maintenance organization;
(4)
a dental plan organization; or
(5)
any other person that provides health benefit plans subject to regulation by the State.
(ii)
“Carrier” includes an entity that arranges a provider panel for a carrier.
(3)
“Contract” means the implied or express agreement between a health care provider and carrier, including the rights, obligations, and fee schedule for the provision of health care services.
(4)
“Health care provider” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.
(b)
(1)
A carrier may not in any manner assign, transfer, or subcontract a health care provider’s contract, wholly or partly, to an insurer that offers personal injury protection coverage under § 19-505 of this article without first informing the health care provider and obtaining the health care provider’s express written consent.
(2)
A carrier may not terminate, limit, or otherwise impair the contract or employment of a health care provider with the carrier on the basis that the health care provider refused to agree to an assignment, transfer, or subcontract of all or part of the health care provider’s contract to an insurer that offers personal injury protection coverage under § 19-505 of this article.
(c)
(1)
A carrier that uses a provider panel for health care services may not require a health care provider, as a condition of participation or continuation on the carrier’s provider panel for health care services, to also serve on a provider panel for workers’ compensation services.
(2)
A carrier may not terminate, limit, or otherwise impair a contract or an agreement with a health care provider, or terminate or limit the employment of a health care provider, based on the health care provider’s election not to serve on a provider panel for workers’ compensation services.
(3)
A carrier shall include in a contract or an agreement with a health care provider a disclosure that informs the health care provider of the right to elect not to serve on a provider panel for workers’ compensation services.
Md. Code Ann., Ins. § 15-126 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–126LinkCopy Citation
(a)
In this section, “emergency medical condition” means a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in:
(1)
placing the patient’s health in serious jeopardy;
(2)
serious impairment to bodily functions; or
(3)
serious dysfunction of any bodily organ or part.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups under health insurance policies that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
(1)
An entity subject to this section may not establish or promote an emergency medical response and transportation system that encourages or directs access by an insured or enrollee in competition with or in substitution of the Maryland Emergency Medical Services System (911) or other State, county, or local government emergency medical services system.
(2)
Notwithstanding paragraph (1) of this subsection, an entity subject to this section may use transportation outside the 911 or other government emergency medical services system for services that are not in response to an emergency medical condition.
(d)
An entity subject to this section may not require an insured or enrollee to obtain prior authorization before accessing the 911 system or other State, county, or local government emergency medical services system for an emergency medical condition.
(e)
An entity subject to this section may not use false or misleading language in its enrollment sales materials or in any other materials provided to insureds or enrollees to discourage or prohibit insureds or enrollees from accessing the 911 system for an emergency medical condition.
Md. Code Ann., Ins. § 15-127 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–127LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Behavioral health care administrative expenses” means any expenses that are for administrative functions including:
(1)
billing and collection expenses;
(2)
accounting and financial reporting expenses;
(3)
quality assurance and utilization management program or activity expenses;
(4)
promotion and marketing expenses;
(5)
taxes, fees, and assessments;
(6)
legal expenses;
(7)
salary expenses for employees that are not related to the delivery of behavioral health care services to patients;
(8)
computer expenses;
(9)
provider credentialing;
(10)
collection and administrative review of treatment plans;
(11)
auditing the financial report submitted to the Commissioner under this section;
(12)
debt payment and debt service; and
(13)
other general and administrative expenses.
(ii)
“Behavioral health care administrative expenses” does not include expenses incurred for behavioral health care services.
(3)
(i)
“Behavioral health care services” means procedures or services rendered by a health care provider for the treatment of mental illness, emotional disorders, drug abuse, or alcohol abuse.
(ii)
“Behavioral health care services” includes any quality assurance or utilization management activities or treatment plan reviews that are clinical in nature.
(iii)
“Behavioral health care services” does not include administrative functions.
(4)
“Carrier” means:
(i)
a health insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a preferred provider organization;
(v)
a third party administrator; or
(vi)
except for a managed care organization as defined in Title 15, Subtitle 1 of the Health – General Article, any other person that provides health benefit plans subject to regulation by the State.
(5)
“Direct behavioral health care expenses” means any payment to a health care provider by a managed behavioral health care organization for the provision of behavioral health care services to a member.
(6)
“Direct payments” means the money that a carrier disburses to a managed behavioral health care organization for the provision of behavioral health care services to a member.
(7)
“Managed behavioral health care organization” means a company, organization, private review agent, or subsidiary that:
(i)
contracts with a carrier to provide, undertake to arrange, or administer behavioral health care services to members; or
(ii)
otherwise makes behavioral health care services available to members through contracts with health care providers.
(8)
(i)
“Member” means an individual entitled to behavioral health care services from a carrier or a managed behavioral health care organization under a policy or plan issued or delivered in the State.
(ii)
“Member” includes a subscriber.
(9)
“Provider” means a person licensed, certified, or otherwise authorized under the Health Occupations Article or the Health – General Article to provide health care services.
(b)
This section does not apply to a person that, for an administrative fee only, solely arranges a provider panel for a carrier for the provision of behavioral health care services on a discounted fee–for–service basis.
(c)
(1)
A carrier that owns or contracts with a managed behavioral health care organization shall distribute to its members at the time of enrollment an explanation of:
(i)
the specific behavioral health care services covered and the specific exclusions under the member’s contract;
(ii)
the member’s responsibilities for obtaining behavioral health care services;
(iii)
the reimbursement methodology that the carrier and managed behavioral health care organization use to reimburse providers for behavioral health care services; and
(iv)
the procedure that a member must utilize when attempting to obtain behavioral health care services outside the network of providers used by the carrier or managed behavioral health care organization.
(2)
The explanation that a carrier is required to distribute under paragraph (1)(iii) of this subsection shall be consistent with § 15–121(c) of this subtitle.
(3)
A carrier that owns or contracts with a managed behavioral health care organization shall:
(i)
include information on behavioral health care providers in the list of providers on the carrier’s provider panel required under § 15–112(n) of this subtitle; and
(ii)
provide the same information on behavioral health care providers that is required for other providers under § 15–112(n) of this subtitle.
(4)
(i)
A carrier that contracts with a managed behavioral health care organization shall require the managed behavioral health care organization to provide to the carrier on an annual basis a report on the direct behavioral health care expenses of the managed behavioral health care organization.
(ii)
The report required under subparagraph (i) of this paragraph shall be made publicly available by the carrier.
(d)
(1)
Each carrier that provides behavioral health care services through a company owned wholly or in part by the carrier or through a contract with a managed behavioral health care organization shall complete and maintain a form developed by the Commissioner that includes the following information:
(i)
the carrier’s direct payments for the preceding calendar year;
(ii)
the information required to be collected by a carrier under subsection (c)(4) of this section; and
(iii)
reported separately from the information required under item (ii) of this paragraph, the carrier’s total expenses for quality assurance and utilization management activities and treatment plan reviews that are clinical in nature.
(2)
The Commissioner shall develop a form to implement the requirements of this subsection.
(e)
(1)
Each carrier required under subsection (d) of this section to complete and maintain the form developed by the Commissioner shall make copies of the form publicly available to an individual, enrollee, or member, upon request.
(2)
A carrier that is required to make a form publicly available to an individual, enrollee, or member under paragraph (1) of this subsection may charge:
(i)
a reasonable preparation fee not to exceed $15 for each form requested; and
(ii)
the actual cost for any postage and handling required to provide copies of the requested forms.
(f)
The Commissioner may adopt regulations to carry out the provisions of this section.
Md. Code Ann., Ins. § 15-129 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–129LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Aggregate attachment point” means the percentage of expected claims in a policy year above which the medical stop–loss insurer assumes all or part of the liability for losses incurred by the insured.
(3)
“Carrier” means:
(i)
an insurer; or
(ii)
a nonprofit health service plan.
(4)
“Expected claims” means the amount of claims that, in the absence of medical stop–loss insurance, are projected to be incurred by the insured using reasonable and accepted actuarial principles.
(5)
“Medical stop–loss insurance” means insurance, other than reinsurance, that is purchased by a person, other than a carrier or a health care provider, to protect the person against catastrophic, excess, or unexpected losses incurred by that person’s obligations to third parties under the terms of a health benefit plan.
(6)
“Medical stop–loss insurer” means a carrier that is authorized to sell, issue, and deliver policies of medical stop–loss insurance in the State.
(7)
“Small employer” has the meaning stated in § 31–101 of this article.
(8)
“Specific attachment point” means the dollar amount in losses attributable to a single individual in a policy year beyond which the medical stop–loss insurer assumes all or part of the liability for losses incurred by the insured.
(b)
Subject to subsection (d)(2) of this section, this section applies to each medical stop–loss insurer and each medical stop–loss insurance policy or contract that is delivered or issued for delivery in the State.
(c)
Medical stop–loss insurance may only be sold, issued, or delivered in the State by a carrier that holds a certificate of authority issued by the Commissioner that authorizes the carrier to engage in the business of health insurance or to act as a nonprofit health service plan.
(d)
(1)
Except as provided in paragraph (2) of this subsection, a medical stop–loss insurer may not issue, renew, deliver, or offer a policy or contract of medical stop–loss insurance, if the policy or contract has:
(i)
a specific attachment point of less than $22,500; or
(ii)
an aggregate attachment point of less than 120% of expected claims.
(2)
This subsection does not apply to:
(i)
a policy or contract of medical stop–loss insurance issued or delivered before June 1, 2015, if the policy or contract maintains:
(1)
a specific attachment point of no less than $10,000; and
(2)
an aggregate attachment point of no less than 115% of expected claims;
(ii)
a renewal of a policy or contract described in item (i) of this paragraph; or
(iii)
a policy or contract of medical stop–loss insurance issued or delivered on or after June 1, 2015, if the policy or contract:
(1)
is issued or delivered to an employer that on May 31, 2015, held a policy or contract of medical stop–loss insurance with:
(A)
a specific attachment point of not less than $10,000; and
(B)
an aggregate attachment point of not less than 115% of expected claims; and
(2)
maintains:
(A)
a specific attachment point of not less than $10,000; and
(B)
an aggregate attachment point of not less than 115% of expected claims.
(e)
For a stop–loss insurance policy or contract issued to a small employer, a medical stop–loss insurer may not:
(1)
(i)
impose higher cost sharing for a specific individual within a small employer’s health benefit plan than is required for other individuals within the small employer’s health benefit plan; or
(ii)
decrease or remove stop–loss coverage for a specific individual within a small employer’s health benefit plan; or
(2)
exclude any employee or dependent from a policy or contract on the basis of an actual or expected health status–related factor or condition, including:
(i)
physical or behavioral health, including mental illness or substance use disorder;
(ii)
claims experience;
(iii)
medical history;
(iv)
receipt of health care;
(v)
genetic information;
(vi)
disability;
(vii)
evidence of insurability, including conditions arising out of acts of domestic violence against an employee or dependent; or
(viii)
any other health status–related factor as determined by the Commissioner.
(f)
For a stop–loss insurance policy or contract issued to a small employer, a medical stop–loss insurer shall:
(1)
guarantee rates for at least 12 months, without adjustment, unless there is a change in:
(i)
the benefits provided under the small employer’s health benefit plan during the policy or contract period;
(ii)
the ownership and control of the small employer; or
(iii)
the number of covered lives by a significant percentage resulting from an event such as an acquisition or a divestiture;
(2)
pay stop–loss claims incurred during the policy or contract period and submitted within 12 months after the expiration date of the policy or contract; and
(3)
disclose to the small employer, in a form and manner approved by the Commissioner and before entering into a policy or contract for medical stop–loss insurance:
(i)
the total costs of the policy or contract;
(ii)
(1)
the dates on which the policy or contract takes effect and terminates; and
(2)
provisions for renewing the policy or contract;
(iii)
the aggregate attachment point and the specific attachment point for the policy or contract; and
(iv)
any limitations on coverage.
(g)
A medical stop–loss insurer who offers or issues a medical stop–loss insurance policy or contract that does not meet the requirements of this section shall be subject to the sanctions set forth in § 4–113 of this article for authorized insurers and § 4–212 of this article for unauthorized insurers.
(h)
Nothing in this section shall be construed as:
(1)
imposing any requirement or duty on any person other than a carrier; or
(2)
treating any medical stop–loss insurance policy as a policy of individual, group, or blanket health insurance covering the participants in the underlying health benefit plan.
Md. Code Ann., Ins. § 15-130 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–130LinkCopy Citation
(a)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs on an outpatient basis under health insurance policies or contracts that are issued or delivered in the State;
(ii)
health maintenance organizations that provide coverage for prescription drugs on an outpatient basis under contracts that are issued or delivered in the State;
(iii)
managed care organizations, as defined in § 15–101 of the Health – General Article, that provide coverage for prescription drugs on an outpatient basis under contracts that are issued or delivered in the State; and
(iv)
to the extent consistent with State and federal law, third party administrators.
(2)
This section does not apply to:
(i)
short–term travel or accident–only policies;
(ii)
short–term nonrenewable policies of not more than 3 months duration; or
(iii)
any health maintenance organization that operates or maintains its own pharmacies and dispenses, on an annual basis, over 95% of prescription drugs on an outpatient basis to its enrollees at its own pharmacies.
(b)
Each entity subject to this section shall provide to its insureds, subscribers, or enrollees a health insurance benefit card, prescription benefit card, or other technology that:
(1)
(i)
complies with the standards set forth in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide in effect at the time of issuance of the card or other technology; or
(ii)
includes, at a minimum, the following data elements:
(1)
the name or identifying trademark of the entity subject to this section or, if another entity administers the prescription benefit, the name or identifying trademark of the benefit administrator;
(2)
the name and identification number of the insured, subscriber, or enrollee;
(3)
the telephone number that providers may call for pharmacy benefit assistance; and
(4)
all electronic transaction routing information and other numbers required by the entity subject to this section or benefit administrator to process a prescription claim electronically; and
(2)
indicates which State agency regulates, in whole or in part, the policy or contract offered by the entity by:
(i)
for an entity subject to the Administration, displaying “MIA” prominently; or
(ii)
for an entity subject to the Maryland Department of Health, displaying “MDH” prominently.
(c)
If an entity subject to this section contracts with or otherwise arranges for the prescription benefit to be administered by another subsidiary or entity, including a pharmacy benefit manager, the entity subject to this section shall require the benefit administrator to comply with this section.
(d)
(1)
The health insurance benefit card, prescription benefit card, or other technology shall be issued to each insured, subscriber, or enrollee by an entity subject to this section.
(2)
If a change occurs in any of the data elements required under subsection (b)(1)(ii) of this section, an entity subject to this section shall:
(i)
reissue a health insurance benefit card, prescription drug benefit card, or other technology; or
(ii)
provide the insured, subscriber, or enrollee with the corrective information necessary to electronically process a prescription claim.
(e)
An entity subject to this section may comply with this section by issuing to each insured, subscriber, or enrollee a health insurance benefit card that contains data elements related to both prescription and nonprescription health insurance benefits.
(f)
The Maryland Department of Health shall adopt regulations to enable managed care organizations to comply with:
(1)
the requirements of this section; and
(2)
any unique requirements of the HealthChoice Program that relate to the electronic processing of claims.
Md. Code Ann., Ins. § 15-130.1 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–130.1LinkCopy Citation
(a)
This section applies to:
(1)
each health insurer;
(2)
each nonprofit health service plan;
(3)
each health maintenance organization; and
(4)
each managed care organization, as defined in § 15–101 of the Health – General Article.
(b)
Each entity subject to this section shall provide to each insured, subscriber, or enrollee of a policy or contract that meets the definition of minimum essential coverage, as described in 26 C.F.R. § 1.5000a–2, a health insurance benefit card, prescription benefit card, or other technology that indicates which State agency regulates, in whole or in part, the policy or contract offered by the entity by:
(1)
for an entity subject to the Administration, displaying “MIA” prominently; or
(2)
for an entity subject to the Maryland Department of Health, displaying “MDH” prominently.
(c)
This section may not be construed to preclude an entity subject to this section from including:
(1)
any other information required to be included under this article; or
(2)
any information that is in addition to the information required under this section.
Md. Code Ann., Ins. § 15-131 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–131LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide, directly or through a pharmacy benefit manager, coverage for prescription drugs under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide, directly or through a pharmacy benefit manager, coverage for prescription drugs under contracts that are issued or delivered in the State.
(b)
If an entity subject to this section requires a pharmacy to submit a request for payment electronically, then the pharmacy or designated agent may choose to be reimbursed electronically, and in that event the entity shall reimburse the pharmacy electronically, and shall provide the appropriate payment data electronically.
(c)
An entity subject to this section may not impose a processing fee for the electronic reimbursement or for providing payment data electronically.
Md. Code Ann., Ins. § 15-132 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–132LinkCopy Citation
(a)
In this section, “carrier” has the meaning stated in § 19–142 of the Health – General Article.
(b)
A carrier shall provide incentives to health care providers in accordance with the requirements of Title 19, Subtitle 1, Part IV of the Health – General Article.
Md. Code Ann., Ins. § 15-133 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–133LinkCopy Citation
On or before December 1 of each year, the Commissioner shall report to the General Assembly, in accordance with § 2–1257 of the State Government Article, on the estimated number of insured and self–insured contracts for health benefit plans in the State and the number of insured and self–insured lives under the age of 65 enrolled in benefit plans in the State.
Md. Code Ann., Ins. § 15-134 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–134LinkCopy Citation
(a)
In this section, “grandfathered health plan” has the meaning stated in the federal Patient Protection and Affordable Care Act, as amended by the federal Health Care and Education Reconciliation Act of 2010.
(b)
Except as provided in subsection (c) of this section, a provision of this title or Title 14 of this article enacted after January 1, 2010, may not apply to a group health plan that is a grandfathered health plan or health insurance coverage that is a grandfathered health plan if the provision would prevent the group health plan or health insurance coverage from being considered a grandfathered health plan.
(c)
Subsection (b) of this section does not apply to any provision of this title or Title 14 of this article enacted after January 1, 2010, to enforce a provision of federal law that was enacted on or before January 1, 2010.
Md. Code Ann., Ins. § 15-135 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–135LinkCopy Citation
(a)
(1)
In this section, “annual preventive care” means an annual preventive visit, screening, or examination that is a covered benefit under a policy or contract issued or delivered by an entity subject to this section.
(2)
“Annual preventive care” includes, if the service is a covered benefit:
(i)
an annual child wellness visit;
(ii)
a routine gynecological visit;
(iii)
a screening test or examination for colorectal cancer, chlamydia, human papillomavirus, prostate cancer, or breast cancer; and
(iv)
an annual vision visit that includes a vision examination.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section that provides covered benefits for annual preventive care shall provide coverage for the annual preventive care if:
(1)
the annual preventive care is provided no more than once at any time during the plan year established in the policy or contract; and
(2)
any other requirements for coverage of the annual preventive care are met.
(d)
This section may not be construed to require coverage for a service not otherwise required by law.
Md. Code Ann., Ins. § 15-135.1 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–135.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means an insurer, nonprofit health service plan, health maintenance organization, or dental plan organization that provides dental benefits on an expense–incurred basis under policies or contracts issued or delivered in the State.
(3)
“Dental preventive care” means a preventive dental visit, screening, oral examination, teeth cleaning (prophylaxis), fluoride treatment, or routine preventive service that is a covered benefit under a policy or contract issued or delivered by a carrier.
(b)
If benefits for dental preventive care are available and all other requirements for the coverage of dental preventive care are met, a carrier shall provide coverage for dental preventive care:
(1)
at any time during the plan year for a policy or contract that provides coverage for dental preventive care once during the plan year; or
(2)
subject to subsection (c) of this section, in accordance with any frequency limitation for a policy or contract that provides coverage for dental preventive care more than once during the plan year.
(c)
A carrier may not impose a frequency limitation on dental preventive care that requires the dental preventive care to be provided at an interval greater than 120 days during a plan year.
(d)
This section may not be construed to require coverage for a service not otherwise required by law.
Md. Code Ann., Ins. § 15-136 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–136LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization; or
(iv)
any other person that provides health benefit plans subject to regulation by the State.
(3)
“Group model health maintenance organization” has the meaning stated in § 19–713.6(a) of the Health – General Article.
(b)
This section applies only to contracts or policies that:
(1)
are issued or delivered by a carrier; and
(2)
provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis.
(c)
(1)
Except as provided in subsection (d) of this section, each carrier shall pay a bonus to primary care providers for services provided in the office:
(i)
after 6 p.m. and before 8 a.m.; or
(ii)
on weekends and national holidays.
(2)
A carrier shall provide for and describe the terms of the bonus payment required in paragraph (1) of this subsection in a separate clause in the carrier’s contract with the primary care provider.
(d)
A group model health maintenance organization is not required to make any bonus payments described in subsection (c) of this section to physicians that are employed by the physician group under contract with the group model health maintenance organization.
Md. Code Ann., Ins. § 15-138 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–138LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Ambulance” means any conveyance designed and constructed or modified and equipped to be used, maintained, or operated to transport individuals who are sick, injured, wounded, or otherwise incapacitated.
(3)
“Ambulance service provider” means a provider of ambulance services that:
(i)
is owned, operated, or under the jurisdiction of a political subdivision of the State or a volunteer fire company or volunteer rescue squad; or
(ii)
has contracted to provide ambulance services for a political subdivision of the State.
(4)
“Assignment of benefits” means the transfer by an insured, a subscriber, or an enrollee of health care coverage reimbursement benefits or other rights under a health insurance policy or contract.
(5)
“Carrier” means:
(i)
an insurer that provides benefits on an expense–incurred basis;
(ii)
a nonprofit health service plan; or
(iii)
a health maintenance organization.
(6)
“Nonpreferred provider” has the meaning stated in § 14–201 of this article.
(7)
“Preferred provider” has the meaning stated in § 14–201 of this article.
(8)
“Preferred provider insurance policy” has the meaning stated in § 14–201 of this article.
(b)
This section applies to individual or group policies or contracts issued or delivered in the State by a carrier.
(c)
(1)
Except for a health maintenance organization, a carrier shall reimburse directly an ambulance service provider that obtains an assignment of benefits from an insured, a subscriber, or an enrollee for covered services provided to the insured, subscriber, enrollee, or any other individual covered by a policy or contract issued by the carrier.
(2)
A health maintenance organization shall reimburse an ambulance service provider directly for covered services provided to a subscriber, enrollee, or any other individual covered by a policy or contract issued by the health maintenance organization.
(d)
(1)
This subsection applies to an ambulance service provider that receives direct reimbursement under subsection (c) of this section.
(2)
Except as provided in paragraph (4) of this subsection, an insured, a subscriber, or an enrollee may not be liable to an ambulance service provider for covered services.
(3)
An ambulance service provider or a representative of the ambulance service provider may not:
(i)
collect or attempt to collect from an insured, a subscriber, or an enrollee of a carrier any money owed to the ambulance service provider by the carrier for covered services rendered to the insured, subscriber, or enrollee by the ambulance service provider; or
(ii)
maintain any action against an insured, a subscriber, or an enrollee of a carrier to collect or attempt to collect any money owed to the ambulance service provider by the carrier for covered services rendered to the insured, subscriber, or enrollee by the ambulance service provider.
(4)
An ambulance service provider or a representative of the ambulance service provider may collect or attempt to collect from an insured, a subscriber, or an enrollee of a carrier:
(i)
any copayment, deductible, or coinsurance amount owed by the insured, subscriber, or enrollee for covered services rendered to the insured, subscriber, or enrollee by the ambulance service provider;
(ii)
if Medicare is the primary insurer and the carrier is the secondary insurer, any amount up to the Medicare–approved or limiting amount, as specified under the federal Social Security Act, that is not owed to the ambulance service provider by Medicare or the carrier after coordination of benefits has been completed, for Medicare covered services rendered to the insured, subscriber, or enrollee by the ambulance service provider; and
(iii)
any payment or charge for services that are not covered services.
(e)
(1)
Notwithstanding § 19–710.1 of the Health – General Article, a health maintenance organization’s allowed amount for a covered health care service provided by an ambulance service provider that is not under written contract with the health maintenance organization may not be less than the allowed amount paid to an ambulance service provider that is under written contract with the health maintenance organization for the same covered service in the same geographic region, as defined by the Centers for Medicare and Medicaid Services.
(2)
An insurer’s or nonprofit health service plan’s allowed amount for a health care service covered under a preferred provider insurance policy and provided by an ambulance service provider that is a nonpreferred provider may not be less than the allowed amount paid to an ambulance service provider who is a preferred provider for the same health care service in the same geographic region, as defined by the Centers for Medicare and Medicaid Services.
(f)
The Commissioner may adopt regulations to implement this section.
Md. Code Ann., Ins. § 15-139 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–139LinkCopy Citation
(a)
(1)
In this section, “telehealth” means, as it relates to the delivery of health care services, the use of interactive audio, video, or other telecommunications or electronic technology by a licensed health care provider to deliver a health care service within the scope of practice of the health care provider at a location other than the location of the patient.
(2)
“Telehealth” includes an audio–only telephone conversation between a health care provider and a patient that results in the delivery of a billable, covered health care service.
(3)
“Telehealth” does not include:
(i)
except as provided in paragraph (2) of this subsection, an audio–only telephone conversation between a health care provider and a patient;
(ii)
an electronic mail message between a health care provider and a patient; or
(iii)
a facsimile transmission between a health care provider and a patient.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
(1)
An entity subject to this section:
(i)
shall provide coverage under a health insurance policy or contract for health care services appropriately delivered through telehealth regardless of the location of the patient at the time the telehealth services are provided;
(ii)
may not exclude from coverage a health care service solely because it is provided through telehealth and is not provided through an in–person consultation or contact between a health care provider and a patient; and
(iii)
may not exclude from coverage or deny coverage for a behavioral health care service that is a covered benefit under a health insurance policy or contract when provided in person solely because the behavioral health care service may also be provided through a covered telehealth benefit.
(2)
The health care services appropriately delivered through telehealth shall include counseling and treatment for substance use disorders and mental health conditions.
(d)
(1)
Subject to paragraph (2) of this subsection, an entity subject to this section:
(i)
shall reimburse a health care provider for the diagnosis, consultation, and treatment of an insured patient for a health care service covered under a health insurance policy or contract that can be appropriately provided through telehealth;
(ii)
is not required to:
(1)
reimburse a health care provider for a health care service delivered in person or through telehealth that is not a covered benefit under the health insurance policy or contract; or
(2)
reimburse a health care provider who is not a covered provider under the health insurance policy or contract; and
(iii)
(1)
may impose a deductible, copayment, or coinsurance amount on benefits for health care services that are delivered either through an in–person consultation or through telehealth;
(2)
may impose an annual dollar maximum as permitted by federal law; and
(3)
may not impose a lifetime dollar maximum.
(2)
(i)
When a health care service is appropriately provided through telehealth, an entity subject to this section shall provide reimbursement in accordance with paragraph (1)(i) of this subsection on the same basis and at the same rate as if the health care service were delivered by the health care provider in person.
(ii)
The reimbursement required under subparagraph (i) of this paragraph does not include:
(1)
clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
(2)
any room and board fees.
(iii)
This paragraph may not be construed to supersede the authority of the Health Services Cost Review Commission to set the appropriate rates for hospitals, including setting the hospital facility fee for hospital–provided telehealth.
(e)
Subject to subsection (d)(1)(ii) of this section, an entity subject to this section may not impose as a condition of reimbursement of a covered health care service delivered through telehealth that the health care service be provided by a third–party vendor designated by the entity.
(f)
An entity subject to this section may undertake utilization review, including preauthorization, to determine the appropriateness of any health care service whether the service is delivered through an in–person consultation or through telehealth if the appropriateness of the health care service is determined in the same manner.
(g)
A health insurance policy or contract may not distinguish between patients in rural or urban locations in providing coverage under the policy or contract for health care services delivered through telehealth.
(h)
A decision by an entity subject to this section not to provide coverage for telehealth in accordance with this section constitutes an adverse decision, as defined in § 15–10A–01 of this title, if the decision is based on a finding that telehealth is not medically necessary, appropriate, or efficient.
Md. Code Ann., Ins. § 15-140 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–140LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Acute condition” means a medical or dental condition that:
(i)
involves a sudden onset of symptoms due to an illness, an injury, or any other medical or dental problem that requires prompt medical attention; and
(ii)
has a limited duration.
(3)
“Carrier” means:
(i)
an insurer authorized to sell health insurance;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization; or
(v)
any other entity providing a plan of health insurance, health benefits, or health services authorized under this article or the Affordable Care Act.
(4)
“Enrollee” means:
(i)
a person entitled to health care benefits from a carrier; or
(ii)
a Program recipient who is enrolled in a managed care organization.
(5)
(i)
“Health benefit plan” means a policy, a contract, a certificate, or an agreement offered, issued, or delivered by a carrier to an individual or a group in the State to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
(ii)
“Health benefit plan” does not include:
(1)
coverage only for accident or disability insurance or any combination of accident and disability insurance;
(2)
coverage issued as a supplement to liability insurance;
(3)
liability insurance, including general liability insurance and automobile liability insurance;
(4)
workers’ compensation or similar insurance;
(5)
automobile medical payment insurance;
(6)
credit–only insurance;
(7)
coverage for on–site medical clinics; or
(8)
other similar insurance coverage, specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act, under which benefits for health care services are secondary or incidental to other insurance benefits.
(iii)
“Health benefit plan” does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance, or are otherwise not an integral part of the plan:
(1)
limited scope vision benefits;
(2)
benefits for long–term care, nursing home care, home health care, community–based care, or any combination of these benefits; or
(3)
such other similar limited benefits as are specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act.
(iv)
“Health benefit plan” does not include the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether the benefits are provided under any group health plan maintained by the same plan sponsor:
(1)
coverage only for a specified disease or illness; or
(2)
hospital indemnity or other fixed indemnity insurance.
(v)
“Health benefit plan” does not include the following if offered as a separate policy, certificate, or contract of insurance:
(1)
Medicare Supplemental Insurance (as defined under § 1882(g)(1) of the Social Security Act);
(2)
coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)); or
(3)
similar supplemental coverage provided to coverage under a group health plan.
(6)
(i)
“Health care provider” means:
(1)
a health care practitioner or group of health care practitioners licensed, certified, or otherwise authorized to provide, in the ordinary course of business or practice of a profession, health care services covered in a health benefit plan, the Maryland Medical Assistance Program, or the Maryland Children’s Health Program; or
(2)
a facility where health care is provided to patients or recipients including:
(A)
a hospital, as defined in § 19–301 of the Health – General Article;
(B)
a related institution as defined in § 19–301 of the Health – General Article;
(C)
a freestanding ambulatory care facility as defined in § 19–3B–01 of the Health – General Article;
(D)
a facility that is organized primarily to help in the rehabilitation of persons with disabilities;
(E)
a home health agency as defined in § 19–901 of the Health – General Article;
(F)
a hospice as defined in § 19–901 of the Health – General Article;
(G)
a facility that provides radiological or other diagnostic imagery services;
(H)
a medical laboratory as defined in § 17–201 of the Health – General Article;
(I)
an alcohol abuse and drug abuse treatment program as defined in § 8–403 of the Health – General Article; and
(J)
a Federally Qualified Health Center.
(ii)
“Health care provider” includes the agents, employees, officers, and directors of a health care provider described in subparagraph (i) of this paragraph.
(7)
“Managed care organization” means:
(i)
a certified health maintenance organization that is authorized to receive medical assistance prepaid capitation payments;
(ii)
a corporation that:
(1)
is a managed care system that is authorized to receive medical assistance prepaid capitation payments;
(2)
enrolls only Program recipients or individuals or families served under the Maryland Children’s Health Program; and
(3)
is subject to the requirements of § 15–102.4 of the Health – General Article; or
(iii)
a prepaid dental plan that receives fees to manage dental services.
(8)
“Nonparticipating provider” means a health care provider who is not on the provider panel of a carrier or managed care organization.
(9)
“Participating provider” means a health care provider who is on the provider panel of a carrier or managed care organization.
(10)
“Prior authorization” means a utilization management technique that:
(i)
is used by carriers and managed care organizations;
(ii)
requires prior approval for a procedure, treatment, medication, or service before an enrollee is eligible for full payment of the benefit; and
(iii)
is used to determine whether the procedure, treatment, medication, or service is medically necessary.
(11)
“Program recipient” means an individual who receives benefits under the Maryland Medical Assistance Program.
(12)
(i)
“Provider panel” means the health care providers that contract either directly or through a subcontracting entity with a carrier or managed care organization to provide health care services to the enrollees of the carrier or managed care organization.
(ii)
“Provider panel” does not include an arrangement in which any health care provider may participate solely by contracting with the carrier or managed care organization to provide health care services at a discounted fee–for–service rate.
(13)
“Receiving carrier or managed care organization” means:
(i)
the carrier that issues the new health benefit plan when an enrollee transitions from another carrier or a managed care organization; or
(ii)
the managed care organization that accepts the enrollee when the enrollee transitions from another managed care organization or a carrier.
(14)
“Relinquishing carrier or managed care organization” means:
(i)
the carrier that issued the prior health benefit plan when an enrollee transitions to a new carrier or a managed care organization; or
(ii)
the managed care organization in which an enrollee had been enrolled prior to the enrollee’s transition to a new managed care organization or a carrier.
(15)
“Serious chronic condition” means a medical or dental condition due to a disease, an illness, or any other medical or dental problem that:
(i)
is serious in nature;
(ii)
persists without full cure or worsens over an extended period of time; and
(iii)
is actively managed or supervised by a health care provider to maintain remission or prevent deterioration.
(16)
“Third–party administrator” means an organization under contract with the Maryland Medical Assistance Program to administer certain benefits and services provided by the Maryland Medical Assistance Program.
(b)
(1)
The purpose of this section is to advance the State’s progress in:
(i)
protecting Marylanders from harmful disruptions in health care services; and
(ii)
promoting reasonable continuity of health care for Marylanders when transitioning:
(1)
from one carrier to another carrier; and
(2)
between a carrier and the Maryland Medical Assistance Program or the Maryland Children’s Health Program.
(2)
This section:
(i)
with respect to any benefit or service that is provided through the Maryland Medical Assistance fee–for–service program:
(1)
shall not apply when the enrollee is transitioning from a carrier to the Maryland Medical Assistance Program; and
(2)
except as provided in subsection (c) of this section, shall apply when the enrollee is transitioning from the Maryland Medical Assistance Program to a carrier;
(ii)
shall apply to contracts issued or renewed on or after January 1, 2015; and
(iii)
subject to subparagraph (i) of this paragraph, with respect to dental benefits, shall apply to covered services for which a coordinated treatment plan is in progress.
(c)
(1)
With respect to any benefit or service provided through the Maryland Medical Assistance fee–for–service program, this subsection shall apply:
(i)
only to enrollees transitioning from the Maryland Medical Assistance Program to a carrier; and
(ii)
only to behavioral health and dental benefits, to the extent they are authorized by a third–party administrator.
(2)
Subject to paragraph (3) of this subsection, at the request of an enrollee or an enrollee’s parent, guardian, designee, or health care provider, a receiving carrier or managed care organization shall accept a preauthorization from a relinquishing carrier, managed care organization, or third–party administrator for:
(i)
the procedures, treatments, medications, or services covered by the benefits offered by the receiving carrier or managed care organization; and
(ii)
the following time periods:
(1)
the lesser of the course of treatment or 90 days; and
(2)
the duration of the three trimesters of a pregnancy and the initial postpartum visit.
(3)
Subject to applicable laws relating to the confidentiality of medical records, including 42 C.F.R. Part 2, at the request and with the consent of an enrollee or an enrollee’s parent, guardian, or designee, a relinquishing carrier, managed care organization, or third–party administrator, shall provide a copy of a preauthorization to the enrollee’s receiving carrier or managed care organization within 10 days after receipt of the request.
(4)
After the time periods under paragraph (2)(ii) have lapsed, the receiving carrier or managed care organization may elect to perform its own utilization review in order to:
(i)
reassess and make its own determination regarding the need for continued treatment; and
(ii)
authorize any continued procedure, treatment, medication, or service determined to be medically necessary.
(d)
(1)
Subject to paragraphs (2) through (5) of this subsection, at the request of an enrollee or an enrollee’s parent, guardian, designee, or health care provider, a receiving carrier or managed care organization shall allow a new enrollee to continue to receive health care services being rendered by a nonparticipating provider at the time of the enrollee’s transition to the receiving health benefit plan or managed care organization.
(2)
(i)
The services an enrollee shall be allowed to continue to receive are services for:
(1)
the following conditions:
(A)
acute conditions;
(B)
serious chronic conditions;
(C)
pregnancy; and
(D)
mental health conditions and substance use disorders; and
(2)
any other condition on which the nonparticipating provider and the receiving carrier or managed care organization reach agreement.
(ii)
Examples of conditions set forth in subparagraph (i)1A and B of this paragraph may include:
(1)
bone fractures;
(2)
joint replacements;
(3)
heart attacks;
(4)
cancer;
(5)
HIV/AIDS; and
(6)
organ transplants.
(iii)
An enrollee shall be allowed to continue to receive services for the conditions under this paragraph for the time periods under subsection (c)(2)(ii) of this section.
(3)
(i)
This paragraph does not apply to compensation rates or methods of payment established under § 14–205.2 of this article or § 19–710.1 of the Health – General Article.
(ii)
Subject to paragraphs (4) and (5) of this subsection, the receiving carrier or managed care organization, with respect to the provision of the covered services, shall pay the nonparticipating provider the rate and method of payment the receiving carrier or managed care organization normally would pay and use for participating providers who provide similar services in the same or similar geographic area.
(iii)
The nonparticipating provider may decline to accept the rate or method of payment under subparagraph (ii) of this paragraph by giving 10 days’ prior notice to the enrollee and receiving carrier.
(iv)
Subject to paragraphs (4) and (5) of this subsection, if the nonparticipating provider does not accept the rate or method of payment under subparagraph (ii) of this paragraph, the nonparticipating provider and the receiving carrier or managed care organization may reach agreement on an alternative rate or method of payment for the provision of covered services.
(4)
The rates and methods of payment under paragraph (3)(ii) and (iv) of this subsection shall:
(i)
be subject to any State or federal requirements applicable to reimbursement for health care provider services, including:
(1)
§ 1302(g) of the Affordable Care Act, which applies to reimbursement rates for Federally Qualified Health Centers; and
(2)
Title 19, Subtitle 2 of the Health – General Article, under which the Health Services Cost Review Commission establishes provider rates; and
(ii)
ensure that:
(1)
an enrollee is not subject to balance billing; and
(2)
the copayments, deductibles, and any coinsurance required of an enrollee for the services rendered in accordance with this section are the same as those that would be required if the enrollee were receiving the services from a participating provider of the receiving carrier or managed care organization.
(5)
If the nonparticipating provider does not accept the rate and method of compensation under paragraph (3)(ii) of this subsection, and the carrier or managed care organization does not reach an agreement with the nonparticipating provider for an alternative rate and method of payment under paragraph (3)(iv) of this subsection:
(i)
the nonparticipating provider is not required to continue to provide the services;
(ii)
§ 14–205.3 of this article, under which an enrollee may assign benefits to a nonpreferred provider and the provider may balance bill the enrollee, shall apply to the extent it would apply absent this section; and
(iii)
unless the enrollee has assigned benefits to a nonpreferred provider under § 14–205.3 of this article, the carrier or managed care organization shall facilitate transition of the enrollee to a provider on the provider panel of the carrier or managed care organization.
(e)
(1)
This section does not:
(i)
require a carrier or managed care organization to cover services or provide benefits that are not otherwise covered under the terms and conditions of a health benefit plan, the Maryland Medical Assistance Program, or the Maryland Children’s Health Program; or
(ii)
preclude a carrier or managed care organization from providing continuity of care beyond the requirements of this section within the parameters of the approved rates of the carrier or managed care organization.
(2)
(i)
To ensure continuity of treatment in progress for dental services provided to an enrollee, a relinquishing carrier may elect to allow an enrollee to continue to receive dental services being provided by a participating provider of the relinquishing carrier through an arrangement in which the relinquishing carrier pays the participating provider according to the rate and method of payment the relinquishing carrier normally would pay and use for the participating provider.
(ii)
The rate and method of payment under subparagraph (i) of this paragraph shall comply with:
(1)
the prohibition on balance billing under subsection (d)(4)(ii) of this section; and
(2)
any copayments, deductibles, and coinsurance requirements in the enrollee’s health benefit plan under the relinquishing carrier.
(f)
(1)
A receiving carrier or managed care organization shall provide notice to a new enrollee of the enrollee’s options and responsibilities under this section in a manner prescribed by the Commissioner.
(2)
The requirements of this section are:
(i)
in addition to any other legal, professional, or ethical obligations of a carrier or managed care organization to provide continuity of care; and
(ii)
not intended to limit or make more restrictive any other continuity of care requirements in State or federal law, regulations, or professional codes of conduct.
(g)
The Commissioner and the Secretary of Health each may adopt regulations to enforce the requirements of this section.
(h)
(1)
The Commissioner, the Maryland Health Benefit Exchange, and the Secretary of Health shall collaborate to determine the data, to the extent its collection is feasible and permitted by law, that is necessary to:
(i)
assess the implementation and efficacy of the requirements of this section; and
(ii)
develop a process to evaluate and monitor continuity of care, with particular focus on newly eligible populations, any disparate or discriminatory impact on specific populations, and trends in health disparities.
(2)
On request of the Commissioner, the Maryland Health Benefit Exchange, or the Secretary of Health carriers, managed care organizations, and health care providers shall provide the requisite data.
Md. Code Ann., Ins. § 15-141 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–141LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization; or
(v)
any other person that provides health benefit plans subject to regulation by the State.
(3)
“Enrollee” means a person entitled to health care benefits from a carrier.
(b)
The Commissioner shall develop and make available a standardized form for an enrollee to use to request confidential communications from a carrier in accordance with 45 C.F.R. § 164.522(b).
(c)
A carrier that requires an enrollee to make a request for confidential communications in writing in accordance with 45 C.F.R. § 164.522(b) shall accept the standardized form developed by the Commissioner under this section for that purpose.
(d)
This section may not be construed to limit acceptance by a carrier of any other form of written request from an enrollee for confidential communications from a carrier under 45 C.F.R. § 164.522(b).
Md. Code Ann., Ins. § 15-142 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–142LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Step therapy drug” means a prescription drug or sequence of prescription drugs required to be used under a step therapy or fail–first protocol.
(3)
“Step therapy exception request” means a request to override a step therapy or fail–first protocol.
(4)
(i)
“Step therapy or fail–first protocol” means a protocol established by an insurer, a nonprofit health service plan, or a health maintenance organization that requires a prescription drug or sequence of prescription drugs to be used by an insured or an enrollee before a prescription drug ordered by a prescriber for the insured or the enrollee is covered.
(ii)
“Step therapy or fail–first protocol” includes a protocol that meets the definition under subparagraph (i) of this paragraph regardless of the name, label, or terminology used by the insurer, nonprofit health service plan, or health maintenance organization to identify the protocol.
(5)
“Supporting medical information” means:
(i)
a paid claim from an entity subject to this section for an insured or an enrollee;
(ii)
a pharmacy record that documents that a prescription has been filled and delivered to an insured or an enrollee, or a representative of an insured or an enrollee; or
(iii)
other information mutually agreed on by an entity subject to this section and the prescriber of an insured or an enrollee.
(b)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for prescription drugs through a pharmacy benefits manager is subject to the requirements of this section.
(c)
An entity subject to this section may not impose a step therapy or fail–first protocol on an insured or an enrollee if:
(1)
the step therapy drug has not been approved by the U.S. Food and Drug Administration for the medical condition being treated; or
(2)
a prescriber provides supporting medical information to the entity that a prescription drug covered by the entity:
(i)
was ordered by a prescriber for the insured or enrollee within the past 180 days; and
(ii)
based on the professional judgment of the prescriber, was effective in treating the insured’s or enrollee’s disease or medical condition.
(d)
Subsection (c) of this section may not be construed to require coverage for a prescription drug that is not:
(1)
covered by the policy or contract of an entity subject to this section; or
(2)
otherwise required by law to be covered.
(e)
An entity subject to this section may not impose a step therapy or fail–first protocol on an insured or an enrollee for a prescription drug approved by the U.S. Food and Drug Administration if:
(1)
(i)
the prescription drug is used to treat the insured’s or enrollee’s stage four advanced metastatic cancer; and
(ii)
use of the prescription drug is:
(1)
consistent with the U.S. Food and Drug Administration–approved indication or the National Comprehensive Cancer Network Drugs & Biologics Compendium indication for the treatment of stage four advanced metastatic cancer; and
(2)
supported by peer–reviewed medical literature;
(2)
the prescription drug is insulin or an insulin analog used to treat the insured’s or enrollee’s type 1, type 2, or gestational diabetes; or
(3)
(i)
the prescription drug is prescribed by a treating physician to treat a symptom of or a side effect from treatment of the insured’s or enrollee’s stage four advanced metastatic cancer;
(ii)
use of the prescription drug is:
(1)
consistent with best practices for the treatment of stage four advanced metastatic cancer, a condition associated with stage four advanced metastatic cancer, or a side effect associated with stage four advanced metastatic cancer treatment; and
(2)
supported by peer–reviewed medical literature; and
(iii)
the prescription drug is covered under the terms of the policy or contract of the insured or enrollee.
(f)
(1)
An entity subject to this section shall establish a process for requesting an exception to a step therapy or fail–first protocol that is:
(i)
clearly described, including the specific information and documentation, if needed, that must be submitted by the prescriber to be considered a complete step therapy exception request;
(ii)
easily accessible to the prescriber; and
(iii)
posted on the entity’s website.
(2)
A step therapy exception request shall be granted if, based on the professional judgment of the prescriber and any information and documentation required under paragraph (1)(i) of this subsection:
(i)
the step therapy drug is contraindicated or will likely cause an adverse reaction to the insured or enrollee;
(ii)
the step therapy drug is expected to be ineffective based on the known clinical characteristics of the insured or enrollee and the known characteristics of the prescription drug regimen;
(iii)
the insured or enrollee is stable on a prescription drug prescribed for the medical condition under consideration while covered under the policy or contract of the entity or under a previous source of coverage; or
(iv)
while covered under the policy or contract of the entity or a previous source of coverage, the insured or enrollee has tried a prescription drug that:
(1)
is in the same pharmacologic class or has the same mechanism of action as the step therapy drug; and
(2)
was discontinued by the prescriber due to lack of efficacy or effectiveness, diminished effect, or an adverse event.
(3)
On granting a step therapy exception request, an entity subject to this section shall authorize coverage for the prescription drug ordered by the prescriber for an insured or enrollee.
(4)
An enrollee or insured may appeal a step therapy exception request denial in accordance with Subtitle 10A or Subtitle 10B of this title.
(5)
This subsection may not be construed to:
(i)
prevent:
(1)
an entity subject to this section from requiring an insured or enrollee to try an AB–rated generic equivalent or interchangeable biological product before providing coverage for the equivalent branded prescription drug; or
(2)
a health care provider from prescribing a prescription drug that is determined to be medically appropriate; or
(ii)
require an entity subject to this section to provide coverage for a prescription drug that is not covered by a policy or contract of the entity.
(6)
An entity subject to this section may use an existing step therapy exception process that satisfies the requirements under this subsection.
Md. Code Ann., Ins. § 15-143 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–143LinkCopy Citation
(a)
In this section, “participation agreement” means a contract that:
(1)
is executed by a payor or program administrator and other participating entities; and
(2)
describes the requirements for participation in a payment model subject to this section.
(b)
This section applies only to a payment model described in § 1–302(d)(12) of the Health Occupations Article:
(1)
that applies to individuals covered under health insurance; and
(2)
under which there is cash compensation.
(c)
(1)
Except as provided in paragraph (2) of this subsection, at least 60 days before an exemption provided under § 1–302(d)(12) of the Health Occupations Article for a payment model subject to this section is implemented, the participation agreement and other documents relevant to the payment model under which a compensation arrangement between a health care practitioner and a health care entity is funded or paid shall be filed with the Commissioner.
(2)
The filing under paragraph (1) of this subsection is not required if the compensation arrangement is funded fully by or paid fully under the Medicare or Medicaid program.
(d)
Within 60 days after the documents required under subsection (c)(1) of this section are filed, the Commissioner shall determine if any compensation arrangement between a health care practitioner and a health care entity funded by or paid under the payment model:
(1)
is insurance business; and
(2)
violates this article or a regulation adopted under this article.
(e)
(1)
If the Commissioner determines that a compensation arrangement is insurance business and violates this article or a regulation adopted under this article, the Commissioner shall issue an order to the filer that specifies the ways in which the compensation arrangement violates this article or a regulation adopted under this article.
(2)
(i)
The Commissioner shall hold a hearing before issuing an order under paragraph (1) of this subsection.
(ii)
The Commissioner shall give written notice of the hearing to the filer at least 10 days before the hearing.
(iii)
The notice shall specify the matters to be considered at the hearing.
(3)
If the compensation arrangement between a health care practitioner and a health care entity changes during its term:
(i)
the filer shall submit a revised filing to the Commissioner for review of the changes; and
(ii)
the Commissioner shall make a new determination, as provided under subsection (d) of this section.
(f)
A filing under subsection (c) of this section is subject to the fee required under § 2–112(a)(13) of this article.
Md. Code Ann., Ins. § 15-144 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–144LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer that holds a certificate of authority in the State and provides health insurance in the State;
(ii)
a health maintenance organization that is licensed to operate in the State;
(iii)
a nonprofit health service plan that is licensed to operate in the State; or
(iv)
any other person or organization that provides health benefit plans subject to State insurance regulation.
(3)
“Core treatment” means a standard treatment or course of treatment, therapy, service, or intervention indicated by generally recognized independent standards of current medical practice.
(4)
“Health benefit plan” means:
(i)
for a large group or blanket plan, a health benefit plan as defined in § 15–1401 of this title;
(ii)
for a small group plan, a health benefit plan as defined in § 15–1201 of this title;
(iii)
for an individual plan:
(1)
a health benefit plan as defined in § 15–1301(l) of this title; or
(2)
an individual health benefit plan as defined in § 15–1301(o) of this title;
(iv)
short–term limited duration insurance as defined in § 15–1301(s) of this title; or
(v)
a student health plan as defined in § 15–1318(a) of this title.
(5)
“Medical/surgical benefits” has the meaning stated in 45 C.F.R. § 146.136(a) and 29 C.F.R. § 2590.712(a).
(6)
(i)
“Mental health benefits” means benefits with respect to items or services for mental health conditions that are defined under the terms of a health benefit plan and in accordance with applicable federal and State law, including requirements that:
(1)
any condition defined under the terms of the health benefit plan as being or as not being a mental health condition be defined consistent with generally recognized independent standards of current medical practice and include all conditions, except for substance use disorders, covered under the health benefit plan that:
(A)
fall under any of the diagnostic categories listed in the mental, behavioral, and neurodevelopmental disorders chapter, or equivalent chapter, of the most recent version of the World Health Organization’s International Classification of Diseases adopted by the federal Department of Health and Human Services; or
(B)
are listed in the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders; and
(2)
to the extent generally recognized independent standards of current medical practice do not address whether a condition is a mental health condition, the condition be defined in accordance with applicable federal and State law.
(ii)
“Mental health benefits” does not include medical/surgical benefits or substance use disorder benefits.
(7)
“Nonquantitative treatment limitation” means treatment limitations as defined in 45 C.F.R. § 146.136(a) and 29 C.F.R. § 2590.712(a).
(8)
(i)
“Parity Act” means the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, as amended.
(ii)
“Parity Act” includes 45 C.F.R. § 146.136, 29 C.F.R. § 2590.712, and any other related federal regulations found in the Code of Federal Regulations to implement or enforce the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
(9)
“Parity Act classification” means:
(i)
inpatient in–network benefits;
(ii)
inpatient out–of–network benefits;
(iii)
outpatient in–network benefits;
(iv)
outpatient out–of–network benefits;
(v)
prescription drug benefits; and
(vi)
emergency care benefits.
(10)
“Product” has the meaning stated in § 15–1309(a)(3) of this title.
(11)
(i)
“Substance use disorder benefits” means benefits with respect to items or services for substance use disorders that are defined under the terms of a health benefit plan and in accordance with applicable federal and State law, including requirements that:
(1)
any disorder defined under the terms of the health benefit plan as being or as not being a substance use disorder be defined consistent with generally recognized independent standards of current medical practice and include all disorders covered under the health benefit plan that:
(A)
fall under any of the diagnostic categories listed as a mental or behavioral disorder due to psychoactive substance use, or equivalent category, in the mental, behavioral, and neurodevelopmental disorders chapter, or equivalent chapter, of the most recent version of the World Health Organization’s International Classification of Diseases adopted by the federal Department of Health and Human Services; or
(B)
are listed as a substance–related and addictive disorder, or equivalent category, in the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders; and
(2)
to the extent generally recognized independent standards of current medical practice do not address whether a disorder is a substance use disorder, the disorder shall be defined under the terms of the health benefit plan in accordance with applicable federal and State law.
(ii)
“Substance use disorder benefits” does not include medical/surgical benefits or mental health benefits.
(b)
This section applies to a carrier that delivers or issues for delivery a health benefit plan in the State.
(c)
(1)
Each carrier subject to this section shall:
(i)
for each Parity Act classification, identify all nonquantitative treatment limitations that are applied to mental health benefits, substance use disorder benefits, and medical/surgical benefits;
(ii)
in accordance with the Parity Act and any State regulations adopted under subsection (o) of this section, perform and document comparative analyses of the design and application of all nonquantitative treatment limitations imposed on mental health benefits and substance use disorder benefits;
(iii)
(1)
collect and evaluate relevant data in a manner reasonably designed to assess the impact of each nonquantitative treatment limitation on relevant outcomes related to access to mental health and substance use disorder benefits and medical/surgical benefits; and
(2)
with respect to nonquantitative treatment limitations related to network composition, collect and evaluate relevant data in a manner reasonably designed to assess the aggregate impact of all the nonquantitative treatment limitations on access to mental health and substance use disorder benefits and medical/surgical benefits;
(iv)
provide the comparative analysis, including the evaluation of relevant data, for each nonquantitative treatment limitation requested by the Commissioner within:
(1)
15 working days after a written request; or
(2)
if adopted by the federal government, less than 15 working days to align with the federal rule or regulation;
(v)
within 30 days after a written request, provide the comparative analysis for each nonquantitative treatment limitation and related in operation data analysis, if available and requested by a member in accordance with the Parity Act disclosure requirements or, for members with individual plans, in accordance with subsection (e)(8) of this section; and
(vi)
submit the reports required under paragraph (2) of this subsection.
(2)
On or before July 1, 2024, and every 2 years thereafter, each carrier subject to this section shall submit a report to the Commissioner on each product offered by the carrier in the individual, small, and large group markets to demonstrate the carrier’s compliance with the Parity Act.
(3)
The report submitted under paragraph (2) of this subsection shall include the following information:
(i)
all nonquantitative treatment limitation information required under the Parity Act, subsection (d) of this section, and any State regulations for the products identified under paragraph (2) of this subsection;
(ii)
the results of a comparative analysis, including the evaluation of relevant data, conducted by the carrier on not fewer than five nonquantitative treatment limitations selected by the Commissioner in accordance with paragraph (5) of this subsection; and
(iii)
subject to paragraph (4) of this subsection, a statement, signed by a corporate officer, attesting that, for each product identified under paragraph (2) of this subsection, the selected nonquantitative treatment limitations and the processes, strategies, evidentiary standards, or other factors used in designing and applying the selected nonquantitative treatment limitations to mental health benefits, substance use disorder benefits, and medical/surgical benefits are the same for all plans within the product, as written and in operation.
(4)
If, for any plan within a product identified under paragraph (2) of this subsection, the processes, strategies, evidentiary standards, or other factors used in designing and applying the selected nonquantitative treatment limitations to mental health benefits, substance use disorder benefits, or medical/surgical benefits are different, as written or in operation, from the other plans within the product:
(i)
the statement required under paragraph (3)(iii) of this subsection shall note the exception and identify the plan; and
(ii)
the carrier shall submit a separate comparative analysis for the selected nonquantitative treatment limitations for the plan.
(5)
(i)
In selecting the nonquantitative treatment limitations required to be included for each reporting period, the Commissioner:
(1)
shall prioritize the nonquantitative treatment limitations identified by the Commissioner as having the greatest impact on member access to care;
(2)
shall review the same subset of nonquantitative treatment limitations for each carrier report; and
(3)
may take into consideration other factors determined relevant by the Commissioner, including complaint trends, federal Parity Act guidance, and whether the nonquantitative treatment limitation was selected for a previous reporting year.
(ii)
Of the five selected nonquantitative treatment limitations:
(1)
not more than two may be for utilization review; and
(2)
at least one must be for network composition, including reimbursement rate setting.
(6)
A finding of noncompliance for a product shall apply to all plans within the product.
(7)
If the relevant data evaluated under paragraph (1)(iii) of this subsection indicate that the nonquantitative treatment limitation contributes to material differences in access to mental health and substance use disorder benefits as compared to medical/surgical benefits in a Parity Act classification:
(i)
the differences shall be considered a strong indicator of noncompliance with the Parity Act and may subject the carrier to the provisions of subsection (k) of this section; and
(ii)
the carrier shall submit to the Commissioner documentation of reasonable actions that have been or are being taken to address the material differences to ensure compliance, in operation, with the Parity Act within 15 working days of a request from the Commissioner for the documentation in accordance with this section.
(d)
(1)
A carrier subject to this section shall conduct a comparative analysis for the nonquantitative treatment limitations selected under subsection (c)(5) of this section as nonquantitative treatment limitations are:
(i)
written; and
(ii)
in operation.
(2)
The comparative analysis of the nonquantitative treatment limitations selected under subsection (c)(5) of this section shall:
(i)
demonstrate that the processes, strategies, evidentiary standards, or other factors used in designing and applying each selected nonquantitative treatment limitation to mental health benefits and substance use disorder benefits in each Parity Act classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in designing and applying each selected nonquantitative treatment limitation to medical/surgical benefits within the same Parity Act classification;
(ii)
demonstrate that none of the information, evidence, sources, or standards on which a factor or evidentiary standard is based are biased or not objective in a manner that discriminates against mental health or substance use disorder benefits as compared to medical/surgical benefits;
(iii)
in accordance with the provisions of paragraph (3) of this subsection, demonstrate that the health benefit plan provides meaningful benefits for each covered mental health condition and substance use disorder in every Parity Act classification in which medical/surgical benefits are provided; and
(iv)
include all information required under the Parity Act and any State regulations adopted under subsection (o) of this section.
(3)
(i)
The benefits provided for the mental health condition or substance use disorder shall be compared to the benefits provided for medical conditions and surgical procedures in each Parity Act classification to determine whether benefits are meaningful.
(ii)
Except as provided under subparagraph (iii) of this paragraph, benefits are not meaningful unless coverage is provided for a core treatment for the mental health condition or substance use disorder in each classification in which coverage is provided for a core treatment for one or more medical conditions or surgical procedures.
(iii)
If there is no core treatment for a covered mental health condition or substance use disorder with respect to a Parity Act classification, the health benefit plan:
(1)
is not required to provide benefits for a core treatment for the covered mental health condition or substance use disorder in that Parity Act classification; and
(2)
is required to provide benefits for the covered mental health condition or substance use disorder in every Parity Act classification in which medical/surgical benefits are provided.
(4)
Regardless of whether it was used before the Parity Act was enacted and as requested by the Commissioner, a carrier shall perform and provide a comparative analysis for each process, strategy, evidentiary standard, or other factor used in designing and applying a selected nonquantitative treatment limitation used during a reporting period.
(e)
In providing the analysis required under subsection (d) of this section, a carrier shall:
(1)
identify the factors used to determine that a nonquantitative treatment limitation will apply to a benefit, including:
(i)
the sources for the factors; and
(ii)
if a factor was given more weight than another, the reason for the difference in weighting;
(2)
identify and define the specific evidentiary standards used to define the factors and any other evidence relied on in designing each nonquantitative treatment limitation;
(3)
include the results of the audits, reviews, and analyses performed on the nonquantitative treatment limitations identified under subsection (c)(5) of this section to conduct the analysis required under subsection (d)(2) of this section for the plans and products as written;
(4)
include the relevant data evaluated under subsection (c)(1)(iii) of this section and the results of the audits, reviews, and analyses performed on the nonquantitative treatment limitations identified under subsection (c)(5) of this section to conduct the analysis required under subsection (d)(2) of this section for the plans and products as in operation;
(5)
if the relevant data evaluated under subsection (c)(1)(iii) of this section indicate that the nonquantitative treatment limitation contributes to material differences in access to mental health and substance use disorder benefits as compared to medical/surgical benefits in a Parity Act classification, include an explanation of the differences and a discussion of the actions that have been or are being taken by the carrier to address the differences;
(6)
identify the measures used to ensure comparable design and application of nonquantitative treatment limitations that are implemented by the carrier and any entity delegated by the carrier to manage mental health benefits, substance use disorder benefits, or medical/surgical benefits on behalf of the carrier;
(7)
disclose the specific findings and conclusions reached by the carrier that indicate that the health benefit plan is in compliance with this section and the Parity Act; and
(8)
identify the process used to comply with the Parity Act disclosure requirements for mental health benefits, substance use disorder benefits, and medical/surgical benefits, including:
(i)
the criteria for a medical necessity determination;
(ii)
reasons for a denial of benefits; and
(iii)
in connection with a member’s request for individual or group plan information and for purposes of filing an internal coverage or grievance matter and appeals, plan documents that contain information about processes, strategies, evidentiary standards, and any other factors used to apply a nonquantitative treatment limitation.
(f)
The Commissioner shall:
(1)
develop additional standardized data templates:
(i)
to evaluate the comparative analysis of nonquantitative treatment limitations in operation; and
(ii)
that meet or exceed any minimum requirements for data reporting specified in federal regulations;
(2)
require each carrier subject to this section to submit:
(i)
for each product identified under subsection (c)(2) of this section, the data templates described in item (1) of this subsection for the nonquantitative treatment limitations selected by the Commissioner for the reporting year in accordance with subsection (c)(5) of this section; and
(ii)
a separate data template for any plans described in subsection (c)(4) of this section; and
(3)
post the data templates on the Administration’s website for a comment period of not less than 30 days before adoption.
(g)
The reports required under this section shall:
(1)
be submitted on a standard form developed by the Commissioner that meets or exceeds any minimum requirements specified in the federal regulations and sub–regulatory guidance on nonquantitative treatment limitations reporting;
(2)
be submitted by the carrier that issues or delivers the product;
(3)
be prepared in coordination with any entity the carrier contracts with to provide mental health benefits and substance use disorder benefits;
(4)
contain a statement, signed by a corporate officer, attesting to the accuracy of the information contained in the report;
(5)
be available to plan members and the public on the carrier’s website in a summary form that removes confidential or proprietary information and is developed by the Commissioner in accordance with subsection (n)(2) of this section; and
(6)
exclude any identifying information of any plan member.
(h)
(1)
A carrier submitting a report under this section may submit a written request to the Commissioner that disclosure of specific information included in the report be denied under the Public Information Act and, if submitting a request, shall:
(i)
identify the particular information the disclosure of which the carrier requests be denied; and
(ii)
cite the statutory authority under the Public Information Act that authorizes denial of access to the information.
(2)
The Commissioner may review a request submitted under paragraph (1) of this subsection on receipt of a request for access to the information under the Public Information Act.
(3)
The Commissioner may notify the carrier that submitted the request under paragraph (1) of this subsection before granting access to information that was the subject of the request.
(4)
A carrier shall disclose to a member on request any plan information contained in a report that is required to be disclosed to that member under federal or State law.
(i)
(1)
The Commissioner shall:
(i)
review each report submitted in accordance with subsections (c), (d), and (f) of this section to assess each carrier’s compliance with the Parity Act and any State regulations adopted under subsection (o) of this section for each Parity Act classification;
(ii)
notify a carrier in writing of any noncompliance with the Parity Act or any State regulations adopted under subsection (o) of this section before issuing an administrative order; and
(iii)
within 90 days after the notice of noncompliance is issued, allow the carrier to:
(1)
submit a compliance plan to the Administration to comply with the Parity Act and any State regulations adopted under subsection (o) of this section; and
(2)
reprocess any claims that were improperly denied, in whole or in part, because of the noncompliance.
(2)
The Commissioner may require carriers to complete data templates for a nonquantitative treatment limitation more frequently than every 2 years.
(j)
(1)
If the Commissioner finds that the carrier failed to submit a complete report required under this section, the Commissioner may:
(i)
take action authorized under paragraph (2) of this subsection;
(ii)
in accordance with § 2–208 of this article, charge the carrier for any additional expenses incurred by the Commissioner to review additional reports;
(iii)
impose a penalty for each day that the carrier fails to submit information required by the Commissioner to evaluate compliance; or
(iv)
impose any penalty or take any action as authorized:
(1)
for an insurer, nonprofit health service plan, or any other person subject to this section, under this article; or
(2)
for a health maintenance organization, under this article or the Health – General Article.
(2)
If the Commissioner cannot make a determination that a specific conduct or practice is compliant with the Parity Act because the carrier failed to provide a sufficient comparative analysis for a nonquantitative treatment limitation, the Commissioner may:
(i)
issue an administrative order requiring the carrier or an entity delegated by the carrier to take the following action until the Commissioner can make a determination of compliance with the Parity Act:
(1)
modify the conduct or practice as specified by the Commissioner;
(2)
cease the conduct or practice; or
(3)
submit periodic data related to the conduct or practice; or
(ii)
subject to paragraph (3) of this subsection, require the carrier to perform a new comparative analysis.
(3)
The Commissioner may require the carrier to establish specific quantitative thresholds for evidentiary standards and conduct a new comparative analysis for a nonquantitative treatment limitation if the Commissioner determines a carrier failed to provide a sufficient comparative analysis because the carrier did not:
(i)
use applicable quantitative thresholds for the evidentiary standard; or
(ii)
provide a specific, detailed, and reasoned explanation of how the carrier ensures that the factors for the nonquantitative treatment limitation are being applied comparably and no more stringently to mental health and substance use disorder services.
(4)
Subsection (i)(1)(iii) of this section does not apply to the failure of a carrier to submit a complete report.
(k)
If, as a result of the review required under subsection (i)(1)(i) of this section, the Commissioner finds that the carrier failed to comply with the Parity Act or any State regulations adopted under subsection (o) of this section, and did not submit a compliance plan to adequately correct the noncompliance, the Commissioner may:
(1)
issue an administrative order that requires:
(i)
the carrier or an entity delegated by the carrier to cease the noncompliant conduct or practice; or
(ii)
the carrier to provide a payment that has been denied improperly because of the noncompliance; or
(2)
impose any other penalty or take any action as authorized:
(i)
for an insurer, nonprofit health service plan, or any other person subject to this section, under this article; or
(ii)
for a health maintenance organization, under this article or the Health – General Article.
(l)
(1)
A carrier shall have the burden of persuasion in demonstrating that its design and application of a nonquantitative treatment limitation complies with the Parity Act and any State regulations adopted under subsection (o) of this section:
(i)
in any review conducted by the Commissioner under this section; or
(ii)
in any complaint investigation or market conduct action undertaken by the Commissioner that involves the application of the Parity Act.
(2)
(i)
A failure of a carrier to submit complete Parity Act compliance information required under this section or in connection with an investigation or examination by the Commissioner shall constitute noncompliance with the Parity Act.
(ii)
Subsection (i)(1)(iii) of this section does not apply to a carrier that fails to submit complete Parity Act compliance information.
(m)
In determining an appropriate penalty under subsection (j) or (k) of this section, the Commissioner shall consider the late filing of a report required under subsection (c) or (f) of this section and any parity violation to be a serious violation with a significantly deleterious effect on the public.
(n)
The Commissioner shall create:
(1)
a standard form for entities to submit the reports in accordance with subsection (g)(1) of this section; and
(2)
a summary form for entities to post to their websites in accordance with subsection (g)(5) of this section.
(o)
The Commissioner shall, in consultation with interested stakeholders, adopt regulations to implement this section, including to ensure uniform definitions and methodology for the reporting requirements established under this section.
Md. Code Ann., Ins. § 15-145 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–145LinkCopy Citation
(a)
(1)
In this section the following words having the meanings indicated.
(2)
“Health savings account” has the meaning stated in § 223 of the Internal Revenue Code.
(3)
“High deductible health plan” has the meaning stated in § 223 of the Internal Revenue Code.
(b)
A health savings account is established on the first day that an individual becomes covered by a high deductible health plan.
(c)
The health savings account shall be opened with a trustee or custodian within the time period prescribed by law, without extensions, for filing a federal income tax return for the year in which the health savings account is established.
(d)
A health savings account is established regardless of a transfer of cash or other property to the account and, unless required by the trustee or custodian, it is not necessary for any party to sign a health savings account trust or custodial agreement regarding the health savings account.
Md. Code Ann., Ins. § 15-146 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–146LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Blanket health insurance” means the form of health insurance described in § 15–305 of this title.
(3)
“Health benefit plan” means:
(i)
an individual health benefit plan as defined in § 15–1301(o) of this title;
(ii)
a health benefit plan as defined in § 15–1201 of this title; or
(iii)
a health benefit plan as defined in § 15–1401 of this title.
(4)
“Short–term limited duration insurance” has the meaning stated in § 15–1301(s) of this title.
(b)
The provisions of the federal No Surprises Act and Division BB, Title II, § 201 of the federal Consolidated Appropriations Act, 2021, apply to all insurers, nonprofit health service plans, and health maintenance organizations that deliver or issue for delivery in the State policies or contracts for a health benefit plan or blanket health insurance.
(c)
The provisions of Division BB, Title II, §§ 202 and 203 of the federal Consolidated Appropriations Act, 2021, apply to all insurers, nonprofit health service plans, and health maintenance organizations that deliver or issue for delivery in the State policies or contracts for a health benefit plan, blanket health insurance, or short–term limited duration insurance.
(d)
The Commissioner may enforce this section under any applicable provisions of this article.
Md. Code Ann., Ins. § 15-148 (2026)
Title 15. Health Insurance
Subtitle 1. General Provisions
§ 15–148LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
The Administration shall order the transfer of funds from each entity maintaining a segregated account in accordance with § 1303(b)(2)(B) and (C) of the federal Patient Protection and Affordable Care Act to the Dedicated Purpose Account for the purposes of health care access grants as follows:
(1)
on or before July 1, 2026, 90% of the amount of the ending balance of the segregated account that exceeds disbursements for each of the plan years 2014 through 2024; and
(2)
on or before July 1, 2027, and each July 1 thereafter, 90% of the amount of the ending balance of a segregated account that exceeds disbursements after the 15–month period following the end of a plan year.
Subtitle 1A. Consumer Protections
Md. Code Ann., Ins. § 15-1A-01 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-01LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Carrier” means:
(1)
an insurer that holds a certificate of authority in the State and provides health insurance in the State;
(2)
a health maintenance organization that is licensed to operate in the State;
(3)
a nonprofit health service plan that is licensed to operate in the State; or
(4)
any other person or organization that provides health benefit plans subject to State insurance regulation.
(c)
“Child” means:
(1)
a natural child, a stepchild, a foster child, or an adopted child of the insured; or
(2)
a child placed with the insured for legal adoption.
(d)
“Essential health benefit” means a health benefit that:
(1)
meets the criteria established under § 1302(b) of the Affordable Care Act; or
(2)
if the Commissioner adopts regulations as described in § 15–1A–04 of this subtitle, meets the criteria established by the adopted regulations.
(e)
“Grandfathered plan” means a health benefit plan that:
(1)
meets the criteria established under 45 C.F.R. § 147.140 and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024; or
(2)
if the Commissioner adopts regulations as described in § 15–1A–03 of this subtitle, meets the criteria established by the adopted regulations.
(f)
“Group plan” means a small group plan or a large group plan.
(g)
“Health benefit plan” means an individual plan, a small group plan, or a large group plan.
(h)
“Individual plan” means an individual health benefit plan as defined in § 15–1301(o) of this title.
(i)
“Insured individual” means:
(1)
an insured, an enrollee, a subscriber, a participant, a member, or a beneficiary of a health benefit plan; or
(2)
any covered dependent of a health benefit plan.
(j)
“Large group plan” means a health benefit plan as defined in § 15–1401 of this title.
(k)
“Small group plan” means a health benefit plan as defined in § 15–1201 of this title.
Md. Code Ann., Ins. § 15-1A-02 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-02LinkCopy Citation
(a)
The Commissioner may enforce:
(1)
the provisions of this subtitle; and
(2)
notwithstanding any other provisions of law, the following provisions of Title 1, Subtitles A, C, and D of the Affordable Care Act as they apply to individual health insurance coverage and health insurance coverage offered in the small group and large group markets as those terms are defined in the federal Public Health Service Act, issued or delivered in the State by an authorized insurer, nonprofit health service plan, or health maintenance organization:
(i)
coverage of children up to the age of 26 years;
(ii)
preexisting condition exclusions;
(iii)
policy rescissions;
(iv)
bona fide wellness programs;
(v)
lifetime limits;
(vi)
annual limits for essential benefits;
(vii)
waiting periods;
(viii)
designation of primary care providers;
(ix)
access to obstetrical and gynecological services;
(x)
emergency services;
(xi)
summary of benefits and coverage explanation;
(xii)
minimum loss ratio requirements and premium rebates;
(xiii)
disclosure of information;
(xiv)
annual limitations on cost–sharing;
(xv)
child–only plan offerings in the individual market;
(xvi)
minimum benefit requirements for catastrophic plans;
(xvii)
health insurance premium rates;
(xviii)
coverage for individuals participating in approved clinical trials;
(xix)
contract requirements for stand–alone dental plans sold on the Maryland Health Benefit Exchange;
(xx)
guaranteed availability of coverage;
(xxi)
prescription drug benefit requirements; and
(xxii)
preventive and wellness services and chronic disease management.
(b)
The Commissioner may enforce the provisions identified under subsection (a) of this section under any applicable powers granted to the Commissioner under this article.
Md. Code Ann., Ins. § 15-1A-03 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-03LinkCopy Citation
(a)
For purposes of this subtitle, to the extent necessary, the Commissioner shall adopt regulations that:
(1)
establish criteria that a health benefit plan must meet to be considered a grandfathered plan; and
(2)
are consistent with 45 C.F.R. § 147.140 and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024.
(b)
Except as otherwise provided in this subtitle and subject to subsection (c) of this section, this subtitle applies to any health benefit plan that is offered by a carrier in the State within the scope of:
(1)
Subtitle 12 of this title;
(2)
Subtitle 13 of this title; or
(3)
Subtitle 14 of this title.
(c)
(1)
Except as provided in paragraph (2) of this subsection, the provisions of this subtitle do not apply to a grandfathered plan.
(2)
(i)
The following provisions apply to all grandfathered plans:
(1)
the provisions of § 15–1A–08 of this subtitle related to health benefit plans that provide dependent coverage of a child;
(2)
the provisions of § 15–1A–11 of this subtitle related to the prohibition on establishing lifetime limits on the dollar value of benefits;
(3)
the provisions of § 15–1A–12 of this subtitle related to waiting periods;
(4)
the provisions of § 15–1A–13 of this subtitle related to choice of provider;
(5)
the provisions of § 15–1A–14 of this subtitle related to coverage of emergency services;
(6)
the provisions of § 15–1A–15 of this subtitle related to summary of benefits and coverage requirements;
(7)
the provisions of § 15–1A–16 of this subtitle related to medical loss ratio and corresponding reporting and rebate requirements; and
(8)
the provisions of § 15–1A–21 of this subtitle related to rescission of a health benefit plan.
(ii)
The following provisions apply to all grandfathered plans except grandfathered plans that are individual plans:
(1)
the provisions of § 15–1A–05 of this subtitle related to preexisting condition exclusions; and
(2)
the provisions of § 15–1A–11 of this subtitle related to the prohibition on establishing annual limits on the dollar value of benefits.
Md. Code Ann., Ins. § 15-1A-04 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-04LinkCopy Citation
For purposes of this subtitle, to the extent necessary, the Commissioner shall adopt regulations that:
(1)
establish criteria that a health benefit plan must meet to be considered a health benefit plan that covers essential health benefits; and
(2)
are consistent with 45 C.F.R. Part 156 Subpart B and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024.
Md. Code Ann., Ins. § 15-1A-05 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-05LinkCopy Citation
(a)
This section applies to all grandfathered plans except grandfathered plans that are individual plans and to every health benefit plan that is not a grandfathered plan.
(b)
A carrier may not:
(1)
exclude or limit benefits because a health condition was present before the effective date of coverage; or
(2)
deny coverage because a health condition was present before or on the date of denial.
(c)
The prohibition in subsection (b) of this section applies whether or not:
(1)
any medical advice, diagnosis, care, or treatment was recommended or received for the condition; or
(2)
the health condition was identified as a result of:
(i)
a pre–enrollment questionnaire or physical examination given to an individual; or
(ii)
a review of records relating to the pre–enrollment period.
Md. Code Ann., Ins. § 15-1A-06 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-06LinkCopy Citation
(a)
A carrier may not establish rules for eligibility, including continued eligibility, for enrollment of an individual into a health benefit plan based on health status–related factors, including:
(1)
health condition;
(2)
claims experience;
(3)
receipt of health care;
(4)
medical history;
(5)
genetic information;
(6)
evidence of insurability including conditions arising out of acts of domestic violence; or
(7)
disability.
(b)
A carrier may not require an individual, as a condition of enrollment or continued enrollment in a health benefit plan, to pay a premium or contribution that is greater than the premium or contribution for a similarly situated individual enrolled in the health benefit plan on the basis of any health status–related factor in relation to the individual or to an individual enrolled under the health benefit plan as a dependent of the individual.
Md. Code Ann., Ins. § 15-1A-07 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-07LinkCopy Citation
(a)
(1)
This section may not be construed to limit the authority of the Commissioner to conduct a health benefit plan premium rate review under Title 11, Subtitle 6 of this article.
(2)
This section applies only to a carrier offering an individual plan and, subject to § 15–1205 of this title, a carrier offering a small group plan.
(b)
A carrier may determine a premium rate based on:
(1)
subject to subsection (c) of this section, age;
(2)
geography based on the following contiguous areas of the State:
(i)
the Baltimore metropolitan area;
(ii)
the District of Columbia metropolitan area;
(iii)
Western Maryland; and
(iv)
Eastern Maryland and Southern Maryland;
(3)
subject to subsection (d) of this section, whether the plan covers an individual or a family; and
(4)
subject to subsection (e) of this section, tobacco use.
(c)
(1)
In this subsection, “age” means an individual’s age as of the date of issuance or renewal of a health benefit plan.
(2)
For individuals who are 21 years of age or older, a premium rate based on age:
(i)
may not vary by more than a ratio of 3 to 1 for adults;
(ii)
shall provide for 1–year age bands for individuals at least 21 years old and under the age of 64 years; and
(iii)
shall provide for a single age band for individuals at least 64 years old.
(3)
For individuals who are under the age of 21 years, a premium rate based on age shall:
(i)
be actuarially justified and consistent with the uniform age rating curve established in accordance with paragraph (4) of this subsection;
(ii)
provide for a single age band for individuals under the age of 15 years; and
(iii)
provide for 1–year age bands for individuals at least 15 years old and under the age of 20 years.
(4)
The uniform age rating curve required under paragraph (3)(i) of this subsection may be established by the Commissioner in the individual market, small group market, or both markets.
(d)
(1)
A rating variation for a health benefit plan that provides coverage for a family shall be applied based on the portion of the premium attributable to each family member covered.
(2)
(i)
Subject to subparagraph (ii) of this paragraph, a premium for a health benefit plan that provides coverage for a family shall be determined by summing the premiums for each individual family member.
(ii)
For a health benefit plan that provides family coverage for individuals under the age of 21 years, the sum shall include not more than the premiums for the three oldest individuals under the age of 21 years.
(e)
A premium rate based on tobacco use may not vary by more than a ratio of 1.5 to 1.
Md. Code Ann., Ins. § 15-1A-08 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-08LinkCopy Citation
(a)
A carrier that offers a health benefit plan, including a grandfathered plan, that provides for dependent coverage of a child shall continue to make the coverage available for the child until the child is 26 years old.
(b)
A carrier may not establish rules for eligibility, including continued eligibility, for coverage of a child under the age of 26 years based on any factor other than the relationship between the child and the insured.
Md. Code Ann., Ins. § 15-1A-09 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-09LinkCopy Citation
(a)
Except as provided in subsections (b) through (d) of this section, a carrier shall accept every employer and individual in the State that applies for a health benefit plan, subject to the following provisions of this article:
(1)
Subtitle 4 of this title;
(2)
§§ 15–1206(c), 15–1208.1, 15–1208.2, 15–1209, and 15–1210 of this title;
(3)
§§ 15–1316 and 15–1318 of this title; and
(4)
§§ 15–1406 and 15–1406.1 of this title.
(b)
(1)
Except as provided in paragraph (2) of this subsection, a carrier may restrict enrollment to open or special enrollment periods.
(2)
A carrier that offers a large group plan shall allow an employer eligible to purchase a large group plan to purchase a large group plan at any time during the year.
(c)
If a carrier uses a network for a health benefit plan under which the financing and delivery of medical care are provided, in whole or in part, through a defined set of providers under contract with the carrier, the carrier:
(1)
(i)
may limit the employers that may apply for coverage to employers of eligible individuals who live, work, or reside in the service area for the network; and
(ii)
if the carrier is a health maintenance organization, may limit the individuals who may apply for coverage in the individual market to those who live or reside in the service area for the network; or
(2)
may deny coverage within a service area if the carrier:
(i)
demonstrates to the Commissioner that:
(1)
the carrier does not have the capacity to deliver adequate services to additional enrollees of groups or additional individuals because of its obligations to existing group contract holders and enrollees; and
(2)
the carrier applies the denial of coverage uniformly to all employers and individuals without regard to the claims experience or any health status–related factor; and
(ii)
does not offer coverage within the service area for at least 180 days after the date the carrier denied coverage in the service area.
(d)
A carrier may deny coverage if the carrier:
(1)
demonstrates to the Commissioner that:
(i)
the carrier does not have the financial reserves necessary to underwrite additional coverage; and
(ii)
the carrier applies the denial of coverage uniformly to all employers and individuals without regard to the claims experience or any health status–related factor; and
(2)
unless a later date is otherwise authorized by the Commissioner, does not offer the denied coverage for at least 180 days after the date the carrier denied the coverage.
Md. Code Ann., Ins. § 15-1A-10 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-10LinkCopy Citation
(a)
Subject to subsection (e) of this section and except as provided in subsections (b), (c), and (d) of this section, a carrier shall provide coverage for and may not impose any cost–sharing requirements, including copayments, coinsurance, or deductibles for:
(1)
evidence–based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force with respect to the individual involved;
(2)
immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved, if the recommendation:
(i)
has been adopted by the Director of the Centers for Disease Control and Prevention; or
(ii)
is listed on the Immunization Schedules of the Centers for Disease Control and Prevention for routine use;
(3)
with respect to infants, children, and adolescents, evidence–informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration; and
(4)
with respect to women:
(i)
to the extent not provided in item (ii) of this item, preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of § 2713(a)(4) of the federal Public Health Service Act; and
(ii)
subject to § 15–826(c) of this title, contraceptive coverage as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of § 2713(a)(4) of the federal Public Health Service Act.
(b)
To the extent that cost–sharing is otherwise allowed under federal or State law, a health benefit plan that uses a network of providers may impose cost–sharing requirements on the coverage described in subsection (a) of this section for items or services delivered by an out–of–network provider.
(c)
(1)
In this subsection, “high deductible health plan” has the meaning stated in 26 U.S.C. § 223(c)(2).
(2)
If an insured or enrollee is covered under a high deductible health plan, a carrier may apply the deductible requirement of the high deductible health plan to the coverage required under subsection (a) of this section, unless the Commissioner determines that the coverage is included in the safe harbor provisions for preventive care under 26 U.S.C. § 223(c)(2)(c).
(d)
This section may not be construed to prohibit a carrier from providing coverage for services in addition to those recommended by the United States Preventive Services Task Force or to deny coverage for services that are not recommended by the Task Force.
(e)
Subject to § 15–826(c) of this title, the Commissioner shall enforce this section consistent with the recommendations and guidelines in effect on December 31, 2024, set by the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, or the Health Resources and Services Administration, and related federal rules or guidance, as updated by recommendations issued by the Secretary of Health in accordance with § 18–112 of the Health – General Article.
(f)
A carrier shall provide the coverage described in subsection (a) of this section for plan years that begin on or after the date that is 1 year after the date the recommendations described in subsection (e) of this section are issued.
Md. Code Ann., Ins. § 15-1A-11 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-11LinkCopy Citation
(a)
Except as provided in subsections (b) and (c) of this section, a carrier that offers a health benefit plan, including a grandfathered plan, may not establish lifetime limits or annual limits on the dollar value of benefits for any insured individual.
(b)
To the extent that limits are otherwise authorized under federal or State law, a carrier may establish annual limits on the dollar value of benefits for an insured individual for a grandfathered plan that is an individual plan.
(c)
This section may not be construed to prohibit a carrier from placing annual or lifetime per beneficiary limits on specific covered benefits that are not essential health benefits.
Md. Code Ann., Ins. § 15-1A-12 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-12LinkCopy Citation
A carrier offering a group plan, including a grandfathered plan, may not apply a waiting period of more than 90 days that must pass before coverage becomes effective for an individual who is otherwise eligible for the group plan.
Md. Code Ann., Ins. § 15-1A-13 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-13LinkCopy Citation
(a)
If a carrier requires or provides for the designation of a participating primary care provider for an insured individual, the carrier shall allow each insured individual to designate any participating primary care provider if the provider is available to accept the insured individual.
(b)
(1)
(i)
This subsection applies only to an individual who has a child who is an insured individual under the individual’s health benefit plan.
(ii)
This subsection may not be construed to waive any exclusions of coverage under the terms and conditions of a health benefit plan with respect to coverage of pediatric care.
(2)
If a carrier requires or provides for the designation of a participating primary care provider for a child, the carrier shall allow the individual to designate any participating physician who specializes in pediatrics as the child’s primary care provider if the provider is available to accept the child.
(c)
(1)
(i)
This subsection applies only to a carrier that:
(1)
provides coverage for obstetrical or gynecological care; and
(2)
requires the designation by an insured individual of a participating primary care provider.
(ii)
This subsection may not be construed to:
(1)
waive any exclusions of coverage under the terms and conditions of a health benefit plan with respect to coverage of obstetrical or gynecological care; or
(2)
prohibit a carrier from requiring that the obstetrical or gynecological provider notify the primary care provider or carrier for an insured individual of treatment decisions.
(2)
A carrier shall treat the provision of obstetrical and gynecological care and the ordering of related obstetrical and gynecological items and services by a participating health care provider that specializes in obstetrics or gynecology as care authorized by the primary care provider for the insured individual.
(3)
A carrier may not require authorization or referral by any person, including the primary care provider for the insured individual, for an insured individual who seeks coverage for obstetrical or gynecological care provided by a participating health care provider who specializes in obstetrics or gynecology.
(4)
A health care provider that provides obstetrical or gynecological care shall comply with a carrier’s policies and procedures.
Md. Code Ann., Ins. § 15-1A-14 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-14LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Emergency medical condition” means a medical condition, including a mental health condition or substance use disorder, that manifests itself by acute symptoms of such severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in a condition described in § 1867(e)(1) of the Social Security Act.
(3)
(i)
“Emergency services” means, with respect to an emergency medical condition:
(1)
a medical screening examination that is within the capability of the emergency department of a hospital or freestanding medical facility, including ancillary services routinely available to the emergency department to evaluate an emergency medical condition;
(2)
any other examination or treatment within the capabilities of the staff and facilities available at the hospital or freestanding medical facility that is necessary to stabilize the patient, regardless of the department of the hospital in which the examination or treatment is furnished; or
(3)
except as provided in subparagraph (iii) of this paragraph, additional covered items and services furnished by a health care provider of emergency services that does not have a contractual relationship with the carrier after the patient is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the services described in items 1 and 2 of this subparagraph are furnished.
(ii)
“Emergency services” includes services described in subparagraph (i) of this paragraph that are provided in specialized facilities that are staffed by behavioral health providers trained to provide crisis services.
(iii)
Subject to § 14–205.2 of this article and § 19–710(p) of the Health – General Article, “emergency services” does not include items and services described in subparagraph (i)3 of this paragraph if all of the conditions in 45 C.F.R. § 149.410(b) are met.
(b)
If a carrier provides or covers any benefits for emergency services in an emergency department of a hospital or freestanding medical facility, the carrier:
(1)
may not require prior authorization for the emergency services;
(2)
shall provide coverage for the emergency services regardless of whether the health care provider providing the emergency services has a contractual relationship with the carrier to furnish emergency services;
(3)
may not limit what constitutes an emergency medical condition solely on the basis of diagnosis codes; and
(4)
may not impose any other term or condition on the coverage for emergency services, except for:
(i)
the exclusion or coordination of benefits;
(ii)
a waiting period; and
(iii)
applicable cost–sharing.
(c)
If a health care provider of emergency services does not have a contractual relationship with the carrier to provide emergency services, the carrier:
(1)
may not impose any administrative requirement or limitation on coverage that would be more restrictive than administrative requirements or limitations imposed on coverage for emergency services furnished by a health care provider with a contractual relationship with the carrier;
(2)
subject to § 14–205.2 of this article and § 19–710.1 of the Health – General Article, may not impose any cost–sharing amount greater than the amount imposed for emergency services furnished by a health care provider with a contractual relationship with the carrier;
(3)
shall calculate and apply the cost–sharing amounts in accordance with the requirements of 45 C.F.R. § 149.110(b)(3)(iii) and (v); and
(4)
except as provided in § 14–205.2 of this article and § 19–710.1 of the Health – General Article, shall reimburse the health care provider in accordance with the requirements of 45 C.F.R. § 149.110(b)(3)(iv).
Md. Code Ann., Ins. § 15-1A-15 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-15LinkCopy Citation
(a)
This section applies to all grandfathered plans and to every health benefit plan that is not a grandfathered plan.
(b)
(1)
A carrier shall compile and provide to consumers a summary of benefits and coverage explanation that:
(i)
accurately describes the benefits and coverage under the applicable health benefit plan; and
(ii)
except as provided in paragraph (2) of this subsection, complies with the standards under 45 C.F.R. § 147.200.
(2)
If the Commissioner adopts regulations as described in subsection (c) of this section, a summary of benefits and coverage explanation shall comply with the standards in the adopted regulations.
(c)
To the extent necessary, the Commissioner, in consultation with the Maryland Health Benefit Exchange, shall adopt regulations that:
(1)
establish standards for the summary of benefits and coverage; and
(2)
are consistent with 45 C.F.R. § 147.200 and any corresponding federal rules and guidance in effect December 31, 2024.
(d)
The summary of benefits and coverage shall be presented:
(1)
in a uniform format that does not exceed four pages in length and does not include print smaller than 12 point type; and
(2)
in a culturally and linguistically appropriate manner that uses terminology understandable by the average insured individual.
(e)
The standards developed under subsection (c) of this section shall include:
(1)
uniform definitions of standard insurance–related terms and medical terms so consumers may compare health benefit plans and understand the terms of and exceptions to coverage, including:
(i)
premium;
(ii)
deductible;
(iii)
coinsurance;
(iv)
copayment;
(v)
out–of–pocket limit;
(vi)
preferred provider;
(vii)
nonpreferred provider;
(viii)
out–of–network copayments;
(ix)
usual, customary, and reasonable fees;
(x)
excluded services;
(xi)
grievance and appeals;
(xii)
hospitalization;
(xiii)
hospital outpatient care;
(xiv)
emergency room care;
(xv)
physician services;
(xvi)
prescription drug coverage;
(xvii)
durable medical equipment;
(xviii)
home health care;
(xix)
skilled nursing care;
(xx)
rehabilitation services;
(xxi)
hospice services;
(xxii)
emergency medical transportation; and
(xxiii)
any other terms the Commissioner determines are important to define so a consumer may compare the medical benefits offered by health benefit plans and understand the extent of and exceptions to those medical benefits;
(2)
a description of the coverage of a health benefit plan, including cost–sharing for:
(i)
each of the categories of the essential health benefits in the State benchmark plan selected in accordance with § 31–116 of this article; and
(ii)
other benefits, as identified by the Commissioner;
(3)
the exceptions, reductions, and limitations on coverage;
(4)
the renewability and continuation of coverage provisions;
(5)
a coverage facts label that includes examples to illustrate common benefits scenarios based on recognized clinical practice guidelines, including pregnancy and serious or chronic medical conditions and related cost–sharing requirements;
(6)
a statement of whether the health benefit plan ensures that the plan or coverage share of the total allowed costs of benefits provided under the plan or coverage is not less than 60% of the costs;
(7)
a statement that:
(i)
the summary of benefits is an outline of the health benefit plan; and
(ii)
the language of the health benefit plan should be consulted to determine the governing contractual provisions; and
(8)
a contact number for the consumer to call with additional questions and a website where a copy of the actual health benefit plan can be reviewed and obtained.
(f)
As appropriate, the Commissioner, in consultation with the Maryland Health Benefit Exchange, shall periodically review and update the standards developed under subsection (c) of this section.
(g)
(1)
Each carrier shall provide a summary of benefits and coverage explanation that complies with the standards developed under subsection (c) of this section by the Commissioner to:
(i)
an applicant at the time of application; and
(ii)
an insured individual before the time of enrollment or reenrollment, as applicable.
(2)
A carrier may provide a summary of benefits and coverage explanation as required under paragraph (1) of this subsection in paper or electronic form.
(h)
Except as otherwise provided in this article, if a carrier makes any material modification in any of the terms of the plan or coverage involved that is not reflected in the most recently provided summary of benefits and coverage explanation, the carrier shall provide notice of the modification to insured individuals not later than 60 days before the effective date of the modification.
(i)
(1)
The Maryland Insurance Administration shall levy a fine of not more than $1,000 against a carrier that willfully fails to provide the information required under this section.
(2)
A failure with respect to each insured individual shall constitute a separate offense for purposes of this subsection.
Md. Code Ann., Ins. § 15-1A-16 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-16LinkCopy Citation
(a)
(1)
For purposes of this section, “medical loss ratio”:
(i)
has the meaning established in 45 C.F.R. § 158.221; or
(ii)
if the Commissioner adopts regulations as described in paragraph (2) of this subsection, has the meaning established by the adopted regulations.
(2)
To the extent necessary, the Commissioner shall adopt regulations that:
(i)
establish a definition for “medical loss ratio”; and
(ii)
are consistent with 45 C.F.R. § 158.221 and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024.
(b)
This section applies to all grandfathered plans and to every health benefit plan that is not a grandfathered plan.
(c)
The minimum acceptable medical loss ratio is:
(1)
for the large group market, 85% or a higher percentage as determined by the Commissioner in regulations; and
(2)
for the small group market and individual market, 80% or a higher percentage as determined by the Commissioner in regulations.
(d)
(1)
Except as provided in paragraph (2) of this subsection, each carrier shall comply with the requirements for calculating medical loss ratios and related reporting and rebate requirements established in 45 C.F.R. Part 158 and any corresponding federal rules and guidance.
(2)
If the Commissioner adopts regulations as described in subsection (e) of this section, each carrier shall comply with the requirements in the adopted regulations.
(e)
To the extent necessary, the Commissioner shall adopt regulations that:
(1)
establish requirements for calculating medical loss ratios and related reporting and rebate requirements; and
(2)
are consistent with 45 C.F.R. Part 158 and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024.
Md. Code Ann., Ins. § 15-1A-17 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-17LinkCopy Citation
(a)
(1)
This section may not be construed to require a carrier to disclose information that is proprietary and trade secret information under applicable law.
(2)
This section applies only to carriers offering an individual plan or a small group plan.
(b)
A carrier shall disclose to an individual or employer, as applicable, the following information:
(1)
the carrier’s right to change premium rates and the factors that may affect changes in premium rates; and
(2)
the benefits and premiums available under all health benefit plans for which the employer or individual is qualified.
(c)
The carrier shall make the disclosure required under subsection (b) of this section:
(1)
as part of its solicitation and sales material; or
(2)
if the information is requested by the individual or employer.
(d)
Information disclosed in accordance with subsection (b) of this section shall be:
(1)
provided in a manner determined to be understandable by the average employer or individual; and
(2)
sufficient to reasonably inform the employer or individual of the employer’s or individual’s rights and obligations under the health benefit plan.
Md. Code Ann., Ins. § 15-1A-18 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-18LinkCopy Citation
(a)
A carrier may offer a catastrophic plan in the individual market in accordance with the requirements of this section.
(b)
A catastrophic plan may be offered only to individuals who:
(1)
are under the age of 30 years before the beginning of the plan year; or
(2)
hold certification for a hardship exemption or an affordability exemption as required in subsection (c) of this section.
(c)
(1)
Except as provided in paragraph (2) of this subsection, to be offered a catastrophic plan, an individual shall hold certification for a hardship exemption or an affordability exemption under 42 U.S.C. § 5000A.
(2)
If the Maryland Health Benefit Exchange adopts regulations as described under subsection (d) of this section, an individual shall hold certification for a hardship exemption or an affordability exemption under the regulations adopted by the Exchange.
(d)
To the extent necessary, the Maryland Health Benefit Exchange shall adopt regulations that:
(1)
establish a process for issuing hardship exemptions and affordability exemptions; and
(2)
are consistent with 42 U.S.C. § 5000A and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024.
(e)
(1)
Subject to paragraph (2) of this subsection, a catastrophic plan shall provide coverage for essential health benefits.
(2)
A catastrophic plan shall require a deductible that:
(i)
is equal to the annual limit on cost–sharing described in § 15–1A–19 of this subtitle;
(ii)
applies to essential health benefits;
(iii)
does not apply to at least three primary care visits each plan year; and
(iv)
does not apply to any covered benefits for which a deductible is prohibited under this title.
Md. Code Ann., Ins. § 15-1A-19 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-19LinkCopy Citation
(a)
(1)
In this section, “cost–sharing” means any expenditure required by or on behalf of an insured individual with respect to essential health benefits.
(2)
“Cost–sharing” includes:
(i)
deductibles, coinsurance, copayments, or similar charges; and
(ii)
any other expenditure required of an insured individual that is a qualified medical expense, as defined in 26 U.S.C. § 223(d)(2), with respect to essential health benefits covered under the plan.
(3)
“Cost–sharing” does not include premiums, balance billing amounts for nonnetwork providers, or spending for noncovered services.
(b)
(1)
Except as provided in paragraph (2) of this subsection, each carrier shall comply with annual limitations on cost–sharing for essential health benefits covered under health benefit plans as established by 45 C.F.R. § 156.130.
(2)
If the Commissioner adopts regulations as described in subsection (c) of this section, each carrier shall comply with the adopted regulations.
(c)
To the extent necessary, the Commissioner shall adopt regulations that:
(1)
establish annual limitations on cost–sharing; and
(2)
are consistent with 45 C.F.R. § 156.130 and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024.
Md. Code Ann., Ins. § 15-1A-20 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-20LinkCopy Citation
(a)
(1)
This section applies only to individual plans and small group plans.
(2)
The requirements in this section are in addition to and not in substitution of any other requirements of law related to prescription drug benefits.
(b)
(1)
Except as provided in paragraph (2) of this subsection, an individual plan or a small group plan shall be considered to provide prescription drug essential health benefits only if the individual plan or small group plan complies with 45 C.F.R. § 156.122.
(2)
If the Commissioner adopts regulations as described in subsection (c) of this section, an individual plan or a small group plan shall be considered to provide prescription drug essential health benefits only if the individual plan or small group plan complies with the regulations adopted by the Commissioner.
(c)
To the extent necessary, the Commissioner shall adopt regulations that:
(1)
establish criteria to determine whether an individual plan or a small group plan provides prescription drug essential health benefit coverage; and
(2)
are consistent with 45 C.F.R. § 156.122 and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024.
Md. Code Ann., Ins. § 15-1A-21 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-21LinkCopy Citation
(a)
This section applies to all grandfathered plans and to every health benefit plan that is not a grandfathered plan.
(b)
(1)
Subject to § 15–1106 of this title, a carrier may not rescind the coverage under a health benefit plan unless:
(i)
the insured individual performs an act, a practice, or an omission that constitutes fraud or makes a misrepresentation of material fact as prohibited by the health benefit plan; and
(ii)
except as provided in paragraph (2) of this subsection, the carrier complies with 45 C.F.R. § 147.128.
(2)
If the Commissioner adopts regulations as described in subsection (c) of this section, a carrier that rescinds the coverage under a health benefit plan in accordance with subsection (b) of this section shall comply with the adopted regulations.
(c)
To the extent necessary, the Commissioner shall adopt regulations that:
(1)
establish requirements that a carrier shall comply with to rescind coverage under subsection (b) of this section; and
(2)
are consistent with 45 C.F.R. § 147.128 and any federal rules and guidance as those provisions were in effect December 31, 2024.
Md. Code Ann., Ins. § 15-1A-22 (2026)
Title 15. Health Insurance
Subtitle 1A. Consumer Protections
§ 15–1A-22LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Gender identity” has the meaning stated in § 20–101 of the State Government Article.
(3)
“Sexual orientation” has the meaning stated in § 20–101 of the State Government Article.
(b)
This section does not prohibit a carrier from refusing, withholding, or denying coverage under a health benefit plan to any individual for failure to conform to the usual and regular requirements, standards, and regulations of the carrier, unless the denial is based on discrimination on the grounds of race, sex, color, creed, national origin, marital status, sexual orientation, age, gender identity, or disability.
(c)
This section does not apply to limitations or restrictions related to age or marital status that are specifically authorized or required under this article to limit or restrict eligibility for insurance coverage or benefits.
(d)
A carrier may not refuse, withhold, or deny any individual coverage under a health benefit plan offered by the carrier or otherwise discriminate against any individual because of the individual’s race, sex, creed, color, national origin, marital status, sexual orientation, age, gender identity, or disability.
(e)
The Commissioner and the Commission on Civil Rights shall enforce the provisions of this section as provided for in § 2–202 of this article.
(f)
The Commissioner may adopt regulations necessary to carry out this section consistent with federal statutes, rules, and guidance in effect on December 31, 2024.
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
Md. Code Ann., Ins. § 15-201 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–201LinkCopy Citation
(a)
A policy of health insurance may not be delivered or issued for delivery in the State unless the policy complies with the provisions of this section and other sections of this article.
(b)
Each policy of health insurance shall state explicitly:
(1)
any consideration, including the entire amount of money, given for the policy; and
(2)
the time when the health insurance takes effect and terminates.
(c)
(1)
Except as provided in paragraph (2) of this subsection, each policy of health insurance shall purport to insure only one individual.
(2)
On application by an adult member of a family, a policy of health insurance may insure, originally or by subsequent amendment:
(i)
the applicant, who is deemed the policyholder; and
(ii)
two or more eligible members of the policyholder’s family, including a spouse, dependent child, any other child under a specified age not exceeding 18 years, and any other individual dependent on the policyholder or any other individual related to and resident in the household of the policyholder.
(d)
(1)
In this subsection, “text” includes all printed matter of a policy except the name and address of the insurer, name or title of the policy, any brief description, captions, and subcaptions.
(2)
The style, arrangement, and overall appearance of a policy may not give undue prominence to any part of the text.
(3)
Each printed part of the text and of any endorsements or attached papers shall be printed plainly in lightfaced type:
(i)
of a style in general use; and
(ii)
in a size that is uniform and not less than 10 point with a lower case unspaced alphabet length not less than 120 point.
(e)
(1)
The exceptions and reductions of indemnity shall be set forth in the policy.
(2)
Other than those contained in §§ 15-207 through 15-226 of this subtitle, and except as provided in paragraph (3) of this subsection, the exceptions and reductions shall be printed at the insurer’s option:
(i)
with the benefit provisions to which they apply; or
(ii)
under an appropriate caption such as “Exceptions” or “Exceptions and Reductions”.
(3)
If an exception or reduction specifically applies only to a particular benefit of the policy, a statement of the exception or reduction shall be included with the benefit provision to which it applies.
(f)
Each form of a policy, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page.
(g)
(1)
Except as provided in paragraph (2) of this subsection, a policy may not contain a provision that purports to incorporate in the policy a part of the charter, rules, constitution, or bylaws of the insurer unless the part is set forth in full in the policy.
(2)
A statement of rates, classification of risks, or short-rate table that is filed with the Commissioner may be referred to or incorporated in the policy without being set forth in full.
(h)
(1)
Subject to paragraph (2) of this subsection, a notice shall be prominently printed on or attached to the face of the policy that states that:
(i)
the policy may be surrendered to the insurer for cancellation within 10 days after the date the policy is delivered to the insured; and
(ii)
if a policy is canceled during the 10-day period, a pro rata premium for the unexpired term of the policy shall be returned to the insured.
(2)
The insured shall notify the insurer of the cancellation in writing.
(3)
The insurer may print or attach the notice required under paragraph (1) of this subsection or a notice of equal prominence that, in the opinion of the Commissioner, is not less favorable to the policyholder.
(i)
A policy that is subject to renewal at the option of the insurer shall contain a notice of this provision prominently printed on the first page of the policy.
Md. Code Ann., Ins. § 15-202 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–202LinkCopy Citation
(a)
Except as otherwise provided in this section, each policy of health insurance that is delivered or issued for delivery in the State:
(1)
shall contain the exact language of each provision that is required under §§ 15-207 through 15-218 of this subtitle and any optional provision in §§ 15-207 through 15-226 of this subtitle that is used; and
(2)
shall contain each mandatory provision and any optional provision that is used:
(i)
in the order in which those provisions appear in this subtitle; or
(ii)
as individual items in any part of the policy with other provisions to which they may be logically related, if the resulting policy is not wholly or partly unintelligible, uncertain, or likely to mislead a person to whom the policy is offered, delivered, or issued.
(b)
The insurer may substitute a corresponding provision with different wording for a provision set forth in this subtitle if the corresponding provision is approved by the Commissioner and is not less favorable in any respect to the insured or beneficiary.
(c)
If a provision specified in §§ 15-207 through 15-218 of this subtitle is wholly or partly inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the approval of the Commissioner, shall:
(1)
omit from the policy the inapplicable provision or part of the provision; or
(2)
modify the inconsistent provision or part of the provision to make it consistent with the coverage provided by the policy.
(d)
Each provision shall be preceded individually by the applicable caption shown or, at the option of the insurer, by an appropriate individual or group caption or subcaption that the Commissioner approves.
Md. Code Ann., Ins. § 15-203 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–203LinkCopy Citation
Other than a policy of accident only insurance, each policy of health insurance in which the insurer reserves the right to refuse renewal on an individual basis shall contain a provision, endorsement, or rider that provides in substance:
(1)
that, subject to the right to terminate the policy on nonpayment of premium when due, the right to refuse renewal may not be exercised so as to take effect before the renewal date occurring on, or after and nearest, each anniversary of the policy;
(2)
that a refusal to renew shall be without prejudice to any claim that originates while the policy is in effect;
(3)
that a renewal may not be refused solely because of a change in the health or physical or mental condition of the insured; and
(4)
unless omitted at the insurer’s option, that the right to refuse renewal of a policy of health insurance that was reinstated after lapse may not be exercised so as to take effect before the renewal date occurring on, or after and nearest, each anniversary of the last reinstatement.
Md. Code Ann., Ins. § 15-204 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–204LinkCopy Citation
(a)
If a policy of health insurance establishes, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and the date falls within a period for which the insurer accepts a premium for the policy, or if the insurer accepts a premium for the policy after that date, the coverage provided by the policy continues in effect until the end of the period for which the insurer has accepted the premium.
(b)
If the age of the insured is misstated and, according to the correct age of the insured, the coverage provided by the policy would not have become effective or would have ceased before the acceptance of a premium for the policy, the liability of the insurer is limited to the refund, on request, of the premiums paid for the period not covered by the policy.
Md. Code Ann., Ins. § 15-205 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–205LinkCopy Citation
(a)
A policy of a foreign insurer or alien insurer that is delivered or issued for delivery in the State may contain a provision that:
(1)
is not less favorable to the insured or beneficiary than the provisions of this subtitle; and
(2)
is required by the law of the state or country under which the foreign insurer or alien insurer is organized.
(b)
A policy of a domestic insurer that is issued for delivery in another state or country may contain a provision that is allowed or required by the laws of the other state or country.
Md. Code Ann., Ins. § 15-206 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–206LinkCopy Citation
(a)
A policy provision that is not subject to this subtitle may not make the policy or any part of the policy less favorable in any respect to the insured or beneficiary than the provisions of the policy that are subject to this subtitle.
(b)
A policy that is delivered or issued for delivery in the State in violation of this subtitle is valid but shall be construed as provided in this subtitle.
(c)
Whenever a policy provision that is subject to this subtitle conflicts with a provision of this subtitle, the rights, duties, and obligations of the insurer, insured, and beneficiary shall be governed by this subtitle.
Md. Code Ann., Ins. § 15-207 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–207LinkCopy Citation
Each policy of health insurance shall contain the following provision:
“Entire contract; changes: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be endorsed hereon or attached hereto. No insurance producer has authority to change this policy or to waive any of its provisions.”
Md. Code Ann., Ins. § 15-208 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–208LinkCopy Citation
(a)
Except as provided in subsection (c) of this section, each policy of health insurance shall contain the following provision:
“Time limit on certain defenses: (1) After two years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such two-year period.”
(2)
“No claim for loss incurred or disability (as defined in the policy) commencing after two years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.”
(b)
The first provision set forth in subsection (a) of this section does not:
(1)
affect a legal requirement for avoidance of a policy or denial of a claim during the initial two-year period after the issuance of the policy; or
(2)
limit the application of §§ 15-219 through 15-223 of this subtitle if there is a misstatement with respect to age, occupation, or other insurance.
(c)
(1)
This subsection applies only to a policy that the insured may continue in effect subject to its terms by the timely payment of premiums:
(i)
until the insured is at least 50 years old; or
(ii)
if the policy is issued after the insured is 44 years old, for at least 5 years after its date of issue.
(2)
A policy subject to this subsection may omit the first provision set forth in subsection (a) of this section and substitute the following provision under the caption “incontestable”:
“After this policy has been in force for a period of two years during the lifetime of the insured (excluding any period during which the insured is disabled), it shall become incontestable as to the statements contained in the application.”
(3)
In the provision set forth in paragraph (2) of this subsection, an insurer may omit the clause “excluding any period during which the insured is disabled”.
Md. Code Ann., Ins. § 15-209 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–209LinkCopy Citation
(a)
(1)
Subject to subsection (b) of this section, each policy of health insurance shall contain the following provision:
“Grace period: A grace period of ........ (insert a number not less than ‘7’ days for weekly premium policies, ‘10’ days for monthly premium policies and ‘31’ days for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period this policy shall continue in force.”
(2)
A policy shall provide a grace period of 31 days if the policy:
(i)
allows the policyholder to choose any one of two or more modes of premium payment by remitting an amount stated in the policy for that particular mode of payment; and
(ii)
does not require a formal request by the policyholder to change the mode of premium payment.
(b)
A policy in which the insurer reserves the right to refuse renewal shall state the following provision at the beginning of the provision set forth in subsection (a)(1) of this section:
“Unless not less than thirty days prior to the premium due date the insurer has delivered to the insured or has mailed to his last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.”
Md. Code Ann., Ins. § 15-210 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–210LinkCopy Citation
(a)
Each policy of health insurance shall contain the following provision:
“Reinstatement: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any insurance producer duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the insurer or such insurance producer requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the forty-fifth (45th) day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than ten days after such date. In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than sixty (60) days prior to the date of reinstatement.”
(b)
The last sentence of the provision set forth in subsection (a) of this section may be omitted from a policy that the insured may continue in effect subject to its terms by the timely payment of premiums:
(1)
until the insured is at least 50 years old; or
(2)
if the policy is issued after the insured is 44 years old, for at least 5 years after its date of issue.
Md. Code Ann., Ins. § 15-211 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–211LinkCopy Citation
(a)
Each policy of health insurance shall contain the following provision:
“Notice of claim: Written notice of claim must be given to the insurer within twenty (20) days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the insurer at .......... (insert the location of such office as the insurer may designate for the purpose), or to any authorized insurance producer of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer.”
(b)
In a policy that provides a loss-of-time benefit that may be payable for at least 2 years, an insurer may insert the following provision between the first and second sentences of the provision set forth in subsection (a) of this section:
“Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, he shall, at least once in every six (6) months after having given notice of the claim, give to the insurer notice of continuance of the disability, except in the event of legal incapacity. The period of six (6) months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured’s right to any indemnity which would otherwise have accrued during the period of six (6) months preceding the date on which such notice is actually given.”
Md. Code Ann., Ins. § 15-212 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–212LinkCopy Citation
Each policy of health insurance shall contain the following provision:
“Claim forms: The insurer, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.”
Md. Code Ann., Ins. § 15-213 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–213LinkCopy Citation
Except as provided in § 12–102(c) of this article, each policy of health insurance shall contain the following provision:
“Proofs of loss: Written proof of loss must be furnished to the insurer at its said office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within ninety (90) days after the termination of the period for which the insurer is liable and in case of claim for any other loss within ninety (90) days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one (1) year from the time proof is otherwise required.”
Md. Code Ann., Ins. § 15-214 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–214LinkCopy Citation
(a)
Each policy of health insurance shall contain the following provision:
“Time of payment of claims: Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment, will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid ........ (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.”
(b)
A policy is considered to provide for periodic payment for loss only if the policy contains a specific statement to that effect.
Md. Code Ann., Ins. § 15-215 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–215LinkCopy Citation
(a)
Each policy of health insurance shall contain the following provision:
“Payment of claims: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured’s death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured.”
(b)
(1)
At the option of the insurer, a policy may include either or both of the provisions set forth in paragraphs (2) and (3) of this subsection with the provision set forth in subsection (a) of this section.
(2)
“If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is under eighteen years of age or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $ .......... (insert an amount which shall not exceed $1,000), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.”
(3)
“Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical or surgical services may, at the insurer’s option and unless the insured requests otherwise in writing not later than the time of filing proof of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.”
Md. Code Ann., Ins. § 15-216 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–216LinkCopy Citation
Each policy of health insurance shall contain the following provision:
“Physical examinations and autopsy: The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.”
Md. Code Ann., Ins. § 15-217 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–217LinkCopy Citation
Each policy of health insurance shall contain the following provision:
“Legal actions: No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three (3) years after the written proof of loss is required to be furnished.”
Md. Code Ann., Ins. § 15-218 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–218LinkCopy Citation
(a)
Subject to subsection (b) of this section, each policy of health insurance shall contain the following provision:
“Change of beneficiary: Unless the insured makes an irrevocable designation of beneficiary, the right to change a beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy.”
(b)
An insurer may choose to omit from the provision set forth in subsection (a) of this section the clause:
“Unless the insured makes an irrevocable designation of beneficiary”.
Md. Code Ann., Ins. § 15-219 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–219LinkCopy Citation
A policy of health insurance may contain the following provision:
“Change of occupation: If the insured be injured or contract sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes his occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence or the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation.”
Md. Code Ann., Ins. § 15-220 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–220LinkCopy Citation
A policy of health insurance may contain the following provision:
“Misstatement of age: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.”
Md. Code Ann., Ins. § 15-221 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–221LinkCopy Citation
(a)
A policy of health insurance may contain the following provision:
“Other insurance in this insurer: If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for ........ (insert type of coverage or coverages) in excess of $ ........ (insert maximum limit of indemnity or indemnities) the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his estate.”
(b)
A policy of health insurance may substitute the following provision for the provision set forth in subsection (a) of this section:
“Insurance effective at any one time on the insured under a like policy or policies in this insurer is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the insurer will return all premiums paid for all other such policies.”
Md. Code Ann., Ins. § 15-222 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–222LinkCopy Citation
(a)
A policy of health insurance may contain the following provision:
“Insurance with other insurers: If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the ‘like amount’ of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage.”
(b)
The phrase “-- Expense incurred benefits” shall be added to the caption of the provision set forth in subsection (a) of this section if the provision is included in a policy that contains the policy provision set forth in § 15-223 of this subtitle.
(c)
(1)
A benefit provided for the insured under a compulsory benefit statute, including a workers’ compensation or employer’s liability statute, whether provided by a governmental unit or otherwise, shall be considered “other valid coverage” of which the insurer has had notice.
(2)
The insurer may include in the provision set forth in subsection (a) of this section a definition of “other valid coverage” if the definition:
(i)
is approved as to form by the Commissioner; and
(ii)
is limited to:
(1)
coverage provided by organizations subject to regulation by insurance law or insurance authorities of this State, another state, or a province of Canada;
(2)
coverage provided by hospital or medical service organizations; and
(3)
any other coverage that the Commissioner may approve for inclusion.
(3)
Unless defined otherwise, “other valid coverage” does not include:
(i)
group insurance or automobile medical payments insurance;
(ii)
coverage provided by hospital or medical service organizations; or
(iii)
coverage provided by union welfare plans or by employer or employee benefit organizations.
(4)
“Other valid coverage” may not include third party liability coverage.
Md. Code Ann., Ins. § 15-223 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–223LinkCopy Citation
(a)
A policy of health insurance may contain the following provision:
“Insurance with other insurers: If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro rata portion for the indemnities thus determined.”
(b)
The phrase “-- Other benefits” shall be added to the caption of the provision set forth in subsection (a) of this section if the provision is included in a policy that contains the policy provision set out in § 15-222 of this subtitle.
(c)
(1)
A benefit provided for the insured under a compulsory benefit statute, including a workers’ compensation or employer’s liability statute, whether provided by a governmental unit or otherwise, shall be considered “other valid coverage” of which the insurer has had notice.
(2)
The insurer may include in the provision set forth in subsection (a) of this section a definition of “other valid coverage” if the definition:
(i)
is approved as to form by the Commissioner; and
(ii)
is limited to:
(1)
coverage provided by organizations subject to regulation by insurance law or insurance authorities of this State, another state, or a province of Canada; and
(2)
any other coverage the Commissioner may approve for inclusion.
(3)
Unless defined otherwise, “other valid coverage” does not include:
(i)
group insurance; or
(ii)
coverage provided by union welfare plans or by employer or employee benefit organizations.
(4)
“Other valid coverage” may not include third party liability coverage.
Md. Code Ann., Ins. § 15-224 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–224LinkCopy Citation
(a)
A policy of health insurance may contain the following provision:
“Relation of earnings to insurance: If the total monthly amount of loss-of-time benefits promised for the same loss under all valid loss-of-time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his average monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such two years as shall exceed the pro rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of $200 or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time.”
(b)
The policy provision set forth in subsection (a) of this section may be inserted only in a policy that the insured may continue in effect subject to its terms by the timely payment of premiums:
(1)
until the insured is at least 50 years old; or
(2)
if the policy is issued after the insured is 44 years old, for at least 5 years after its date of issue.
(c)
(1)
The insurer may include in the provision set forth in subsection (a) of this section a definition of “valid loss-of-time coverage” if the definition:
(i)
is approved as to form by the Commissioner;
(ii)
is limited to:
(1)
coverage provided by governmental units or organizations subject to regulation by insurance law or insurance authorities of this State, another state, or a province of Canada;
(2)
any other coverage that the Commissioner may approve for inclusion; or
(3)
a combination of these coverages.
(2)
Unless defined otherwise, “valid loss-of-time coverage” does not include:
(i)
coverage provided for the insured under a compulsory benefit statute, including a workers’ compensation or employer’s liability statute; or
(ii)
coverage provided by union welfare plans or by employer or employee benefit organizations.
Md. Code Ann., Ins. § 15-225 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–225LinkCopy Citation
A policy of health insurance may contain the following provision:
“Unpaid premiums: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.”
Md. Code Ann., Ins. § 15-226 (2026)
Title 15. Health Insurance
Subtitle 2. Individual Health Insurance Policy Forms and Provisions
§ 15–226LinkCopy Citation
A policy of health insurance may contain the following provision:
“Conformity with state statutes: Any provision of this policy which, on its effective date is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes.”
Subtitle 3. Group and Blanket Health Insurance Policy Forms and Provisions
Md. Code Ann., Ins. § 15-301 (2026)
Title 15. Health Insurance
Subtitle 3. Group and Blanket Health Insurance Policy Forms and Provisions
§ 15–301LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Blanket health insurance” means the form of health insurance described in § 15-305 of this subtitle.
(c)
“Group health insurance” means the form of health insurance described in § 15-302 of this subtitle.
Md. Code Ann., Ins. § 15-302 (2026)
Title 15. Health Insurance
Subtitle 3. Group and Blanket Health Insurance Policy Forms and Provisions
§ 15–302LinkCopy Citation
(a)
Group health insurance is health insurance issued to persons specified in this section to cover the groups of individuals described in this section, with or without their dependents or family members, or to cover their dependents or family members.
(b)
(1)
(i)
In this subsection, “employee” may include:
(1)
an officer or manager of the employer;
(2)
a sole proprietor if the employer is a sole proprietorship;
(3)
a partner if the employer is a partnership;
(4)
an officer, manager, or employee of a corporation that is an affiliate or subsidiary of the employer;
(5)
a sole proprietor, partner, or employee of a sole proprietorship or partnership if the businesses of the employer and sole proprietorship or partnership are under common control through stock ownership, contract, or otherwise;
(6)
a retired employee;
(7)
an elected or appointed official of a public body, but only if the policy is issued to insure employees of the public body; and
(8)
a trustee of the fund, employee of the trustee, or both if the duties of the trustee or employee are connected principally with the trusteeship.
(ii)
“Employee” does not include a director of a corporate employer unless the director is otherwise eligible as an employee of the corporation by performing services other than the usual duties of a director.
(2)
A policy of group health insurance may be issued to an employer or the trustees of a fund established by an employer to cover employees of the employer for the benefit of persons other than the employer.
(3)
The employer or trustees to which the policy is issued are deemed the policyholder.
(c)
(1)
In this subsection, “employee” may include a retired employee.
(2)
A policy of group health insurance may be issued to an association, including a labor union, that has a constitution and bylaws and that is organized and maintained in good faith for purposes other than that of obtaining insurance, to cover members, employees, or employees of members of the association for the benefit of persons other than the association or its officers or trustees.
(d)
(1)
In this subsection, “employee” may include:
(i)
an officer or manager of the employer;
(ii)
a sole proprietor if the employer is a sole proprietorship;
(iii)
a partner if the employer is a partnership;
(iv)
a retired employee; and
(v)
a trustee of the fund, employee of the trustee, or both if the duties of the trustee or employee are connected principally with the trusteeship.
(2)
A policy of group health insurance may be issued to the trustees of a fund established by two or more employers in the same or related industry, by one or more labor unions, by one or more employers and one or more labor unions, or by an association described in subsection (b) of this section, to cover employees of the employers, members of the unions, members of the association, or employees of members of the association, for the benefit of persons other than the employers, unions, or association.
(3)
The trustees to which the policy is issued are deemed the policyholder.
(e)
A policy of group health insurance may be issued to a person to which a policy of group life insurance may be issued or delivered in the State, to cover a class or classes of individuals eligible for insurance under the group life policy.
(f)
A policy of group health insurance may be issued to cover any other substantially similar group that, in the discretion of the Commissioner, may be eligible for group health insurance.
Md. Code Ann., Ins. § 15-304 (2026)
Title 15. Health Insurance
Subtitle 3. Group and Blanket Health Insurance Policy Forms and Provisions
§ 15–304LinkCopy Citation
(a)
Except as provided in §§ 14–205.2 and 14–205.3 of this article, and subject to subsection (b) of this section, on request of the policyholder, a policy of group health insurance may contain a provision that all or part of the benefits provided by the policy for hospital, nursing, medical, or surgical services, at the insurer’s option, may be paid directly to the hospital or person that provides the services.
(b)
A policy of group health insurance may not require that hospital, nursing, medical, or surgical services be provided by a particular hospital or person.
(c)
A direct payment made under subsection (a) of this section discharges the insurer’s obligation with respect to the amount paid.
Md. Code Ann., Ins. § 15-305 (2026)
Title 15. Health Insurance
Subtitle 3. Group and Blanket Health Insurance Policy Forms and Provisions
§ 15–305LinkCopy Citation
(a)
(1)
Blanket health insurance is health insurance issued to or in the name of persons specified in this section to cover the groups of individuals described in this section.
(2)
The person to which or in the name of which a policy or contract is issued is deemed the policyholder.
(b)
A policy or contract of blanket health insurance may be issued to a common carrier or an operator, owner, or lessee of a means of transportation, to cover all individuals or all individuals of a class who may become passengers on the common carrier or means of transportation.
(c)
A policy or contract of blanket health insurance may be issued to an employer, to cover all employees, dependents, or guests who are defined by reference to specific hazards that are incident to the activities or operations of the employer or a class of employees, dependents, or guests similarly defined.
(d)
A policy or contract of blanket health insurance may be issued to a school or other institution of learning, a camp or its sponsor, or the head or principal of a school, other institution of learning, or camp, to cover students, campers, supervisors, or employees.
(e)
A policy or contract of blanket health insurance may be issued in the name of a religious, charitable, recreational, educational, or civic organization, to cover participants in activities sponsored by the organization.
(f)
A policy or contract of blanket health insurance may be issued to a sports team or its sponsors, to cover members, officials, and supervisors.
(g)
A policy or contract of blanket health insurance may be issued in the name of a volunteer fire department, first aid group, other similar volunteer group, or agency with jurisdiction over a volunteer fire department, first aid group, or other similar volunteer group, to cover all members of the volunteer fire department or similar volunteer group.
(h)
A policy or contract of blanket health insurance may be issued to cover any other risk, class of risks, or both that, in the discretion of the Commissioner, may be eligible for blanket health insurance.
Md. Code Ann., Ins. § 15-306 (2026)
Title 15. Health Insurance
Subtitle 3. Group and Blanket Health Insurance Policy Forms and Provisions
§ 15–306LinkCopy Citation
(a)
An insurer that is authorized to issue policies of health insurance in the State may issue blanket health insurance.
(b)
A policy of blanket health insurance may not be issued or delivered in the State unless a copy of the form for the policy is filed with the Commissioner in accordance with § 12-203 of this article.
Md. Code Ann., Ins. § 15-308 (2026)
Title 15. Health Insurance
Subtitle 3. Group and Blanket Health Insurance Policy Forms and Provisions
§ 15–308LinkCopy Citation
(a)
An individual who is covered under a policy or contract of blanket health insurance may not be required to complete an individual application.
(b)
An insurer need not provide a certificate to each individual covered under a policy of blanket health insurance.
Md. Code Ann., Ins. § 15-309 (2026)
Title 15. Health Insurance
Subtitle 3. Group and Blanket Health Insurance Policy Forms and Provisions
§ 15–309LinkCopy Citation
(a)
Except as provided in subsections (b) through (d) of this section, benefits under a policy of blanket health insurance are payable to the insured, beneficiaries designated by the insured, or estate of the insured.
(b)
If the insured is under the age of 18 years or is mentally incompetent, benefits under a policy of blanket health insurance may be made payable to the insured’s parents, guardian, or other person who supports the insured.
(c)
If the employer has paid the entire cost of a policy of blanket health insurance, benefits under the policy may be made payable to the employer.
(d)
(1)
Subject to paragraph (2) of this subsection, a policy of blanket health insurance may contain a provision that all or part of the benefits provided by the policy for hospital, nursing, medical, or surgical services, at the insurer’s option, may be paid directly to the hospital or person that provides the services.
(2)
A policy of blanket health insurance may not require that hospital, nursing, medical, or surgical services be provided by a particular hospital or person.
(3)
A direct payment made under paragraph (1) of this subsection discharges the insurer’s obligation with respect to the amount paid.
Md. Code Ann., Ins. § 15-310 (2026)
Title 15. Health Insurance
Subtitle 3. Group and Blanket Health Insurance Policy Forms and Provisions
§ 15–310LinkCopy Citation
A person may not solicit coverage in the State under a policy of group health insurance or blanket health insurance issued in another jurisdiction without the prior written approval of the Commissioner, unless the type of group to be covered conforms substantially to one of the groups described in § 15-302 or § 15-305 of this subtitle.
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
Md. Code Ann., Ins. § 15-401 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–401LinkCopy Citation
(a)
In this section, “date of adoption” means the earlier of:
(1)
a judicial decree of adoption; or
(2)
the assumption of custody, pending adoption, of a prospective adoptive child by a prospective adoptive parent.
(b)
(1)
This subsection applies to:
(i)
each individual health insurance policy that:
(1)
is delivered, issued for delivery, or renewed in the State;
(2)
provides coverage on an expense–incurred basis; and
(3)
provides coverage for a family member of the insured;
(ii)
each group health insurance policy, including a contract issued by a nonprofit health service plan, that:
(1)
is delivered, issued for delivery, or renewed in the State;
(2)
provides coverage on an expense–incurred basis for employees of an employer or employers or members of a union or unions; and
(3)
provides coverage for a family member of a covered employee or member;
(iii)
each individual service or indemnity contract that:
(1)
is delivered, issued for delivery, or renewed in the State by a nonprofit health service plan; and
(2)
provides coverage for a family member of the subscriber;
(iv)
each individual contract that:
(1)
is delivered, issued for delivery, or renewed in the State by a health maintenance organization; and
(2)
provides coverage for a family member of the subscriber; and
(v)
each group contract that:
(1)
is delivered, issued for delivery, or renewed in the State by a health maintenance organization;
(2)
provides coverage for employees of an employer or employers or members of a union or unions; and
(3)
provides coverage for a family member of the covered employee or member.
(2)
Each policy or contract subject to this subsection shall provide that the health insurance benefits applicable:
(i)
for children or grandchildren shall be payable for a newly born or newly adopted dependent child or grandchild from the moment of birth or date of adoption of the child or grandchild; and
(ii)
for a minor for whom guardianship is granted by court or testamentary appointment shall be payable from the date of appointment.
(c)
On request, an insurer or nonprofit health service plan that issues an individual or group health insurance policy that provides coverage on an expense–incurred basis, or a health maintenance organization that issues an individual or group contract, shall offer family members’ coverage to an insured, subscriber, or member regardless of the marital status of the insured, subscriber, or member.
(d)
Each insurer, nonprofit health service plan, or health maintenance organization that issues a policy or contract that does not provide family members’ coverage shall:
(1)
provide notice to the policyholder or contract holder that coverage for a newly born or newly adopted child or grandchild or a minor for whom guardianship is granted by court or testamentary appointment is not provided under the policy or contract; and
(2)
inform the insured, subscriber, or member of the right and conditions to purchase family members’ coverage under this section.
(e)
To be eligible for coverage under this section:
(1)
a grandchild must be a dependent, and in the court–ordered custody, of the insured, subscriber, or member; and
(2)
a minor must be a dependent and in the custody of the insured, subscriber, or member as a result of a guardianship, other than a temporary guardianship of less than 12 months duration, granted by court or testamentary appointment.
(f)
Coverage for a newly born or newly adopted child or grandchild or a minor for whom guardianship is granted by court or testamentary appointment shall consist of coverage for injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.
(g)
If payment of a specific premium or subscription fee is required to provide coverage for a child or grandchild or a minor for whom guardianship is granted by court or testamentary appointment, the policy or contract may require notification of a birth, adoption, or appointment and payment of the required premium or fee to the insurer, nonprofit health service plan, or health maintenance organization within 31 days after the date of birth, date of adoption, or date of court or testamentary appointment in order to continue coverage beyond the 31–day period.
(h)
(1)
An insurer, nonprofit health service plan, or health maintenance organization may require proof that the insured, subscriber, or member is the parent or grandparent of a newly born or newly adopted child or grandchild or guardian of a minor under court or testamentary appointment.
(2)
If the insurer, nonprofit health service plan, or health maintenance organization requires proof under this subsection, the insurer, nonprofit health service plan, or health maintenance organization shall pay the cost of the proof.
Md. Code Ann., Ins. § 15-402 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–402LinkCopy Citation
(a)
This section applies to:
(1)
each individual or group health insurance policy that is issued in the State; and
(2)
each contract that is issued in the State by a nonprofit health service plan or a health maintenance organization.
(b)
(1)
Notwithstanding any limiting age stated in a policy or contract subject to this section, a child, grandchild, or individual for whom guardianship is granted by court or testamentary appointment shall continue to be covered under the policy or contract as a dependent of an employee, member, or other covered individual if the child, grandchild, or individual under guardianship:
(i)
is unmarried;
(ii)
is chiefly dependent for support on the employee, member, or other covered individual; and
(iii)
at the time of reaching the limiting age, is incapable of self–support because of mental or physical incapacity that started before the child, grandchild, or individual under guardianship attained the limiting age.
(2)
A child, grandchild, or individual under guardianship who is covered under this section shall continue to be covered while remaining unmarried, dependent, and mentally or physically incapacitated until the coverage on the employee, member, or other covered individual on whom the child, grandchild, or individual under guardianship is dependent terminates.
(c)
To be eligible for coverage under this section:
(1)
a grandchild must be a dependent, and in the court–ordered custody, of the employee, member, or other covered individual; and
(2)
an individual must be a dependent and in the custody of the employee, member, or other covered individual as a result of a guardianship, other than a temporary guardianship of less than 12 months duration, granted by court or testamentary appointment.
Md. Code Ann., Ins. § 15-403 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–403LinkCopy Citation
(a)
This section applies to:
(1)
each individual health insurance policy that:
(i)
provides coverage on an expense–incurred basis; and
(ii)
provides coverage for a family member of the insured;
(2)
each group health insurance policy that:
(i)
provides coverage on an expense–incurred basis for employees of an employer or employers or members of a union or unions; and
(ii)
provides coverage for a family member of a covered employee or member;
(3)
each individual service or indemnity contract that:
(i)
is issued by a nonprofit health service plan; and
(ii)
provides coverage for a family member of the subscriber;
(4)
each individual contract that:
(i)
is issued by a health maintenance organization; and
(ii)
provides coverage for a family member of the subscriber; and
(5)
each group contract that:
(i)
is issued by a health maintenance organization;
(ii)
provides coverage for employees of an employer or employers or members of a union or unions; and
(iii)
provides coverage for a family member of the covered employee or member.
(b)
Each policy or contract subject to this section shall provide that the same health insurance benefits and eligibility guidelines that apply to any covered dependent are available, on request of the insured, subscriber, employee, or member, to a grandchild who:
(1)
is unmarried;
(2)
is in the court–ordered custody of the insured, subscriber, employee, or member;
(3)
resides with the insured, subscriber, employee, or member;
(4)
is the dependent of the insured, subscriber, employee, or member; and
(5)
has not attained the limiting age under the terms of the policy or contract.
(c)
On request, an insurer that issues an individual or group health insurance policy that provides coverage on an expense–incurred basis, a nonprofit health service plan, or a health maintenance organization shall offer family members’ coverage to an insured or subscriber regardless of the marital status of the insured or subscriber.
(d)
(1)
An insurer, nonprofit health service plan, or health maintenance organization may require proof that the insured or subscriber is the grandparent of the grandchild.
(2)
If the insurer, nonprofit health service plan, or health maintenance organization requires proof under this subsection, the insurer, nonprofit health service plan, or health maintenance organization shall pay the cost of the proof.
Md. Code Ann., Ins. § 15-403.1 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–403.1LinkCopy Citation
(a)
This section applies to:
(1)
each individual health insurance policy that:
(i)
provides coverage on an expense–incurred basis; and
(ii)
provides coverage for a family member of the insured;
(2)
each group health insurance policy that:
(i)
provides coverage on an expense–incurred basis for employees of an employer or employers or members of a union or unions; and
(ii)
provides coverage for a family member of a covered employee or member;
(3)
each individual service or indemnity contract that:
(i)
is issued by a nonprofit health service plan; and
(ii)
provides coverage for a family member of the subscriber;
(4)
each individual contract that:
(i)
is issued by a health maintenance organization; and
(ii)
provides coverage for a family member of the subscriber; and
(5)
each group contract that:
(i)
is issued by a health maintenance organization;
(ii)
provides coverage for employees of an employer or employers or members of a union or unions; and
(iii)
provides coverage for a family member of the covered employee or member.
(b)
Each policy or contract subject to this section shall provide that the same health insurance benefits and eligibility guidelines that apply to any covered dependent are available, on request of the insured, subscriber, employee, or member, to an individual who:
(1)
is unmarried;
(2)
is under testamentary or court appointed guardianship, other than temporary guardianship of less than 12 months duration, of the insured, subscriber, employee, or member;
(3)
resides with the insured, subscriber, employee, or member;
(4)
is the dependent of the insured, subscriber, employee, or member; and
(5)
has not attained the limiting age under the terms of the policy or contract.
(c)
On request, an insurer that issues an individual or group health insurance policy that provides coverage on an expense–incurred basis, a nonprofit health service plan, or a health maintenance organization shall offer family members’ coverage to an insured or subscriber regardless of the marital status of the insured or subscriber.
(d)
(1)
An insurer, nonprofit health service plan, or health maintenance organization may require proof that the insured or subscriber is a guardian under court or testamentary appointment.
(2)
If the insurer, nonprofit health service plan, or health maintenance organization requires proof under this subsection, the insurer, nonprofit health service plan, or health maintenance organization shall pay the cost of the proof.
Md. Code Ann., Ins. § 15-403.2 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–403.2LinkCopy Citation
(a)
In this section, “child dependent of the domestic partner” means an individual who:
(1)
is:
(i)
the natural child, stepchild, adopted child, or grandchild of the domestic partner of an insured;
(ii)
a child placed with the domestic partner of an insured for legal adoption; or
(iii)
a child who is under testamentary or court appointed guardianship, other than temporary guardianship of less than 12 months’ duration, of the domestic partner of an insured;
(2)
is a dependent, as that term is used in 26 U.S.C. §§ 104, 105, and 106, and any regulations adopted under those sections, of the domestic partner of an insured;
(3)
resides with the insured;
(4)
is unmarried; and
(5)
is under the age of 25 years.
(b)
This section applies to each individual or group policy or contract that:
(1)
allows family coverage; and
(2)
is issued by:
(i)
an insurer or nonprofit health service plan that provides inpatient hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; or
(ii)
a health maintenance organization that provides inpatient hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
Each policy or contract subject to this section shall provide that the same health insurance benefits and eligibility guidelines that apply to any covered dependent are available to a domestic partner of an insured or a child dependent of the domestic partner of an insured at the request of:
(1)
an insured under an individual policy or contract that is subject to this section; or
(2)
the group policyholder of a group policy or contract that is subject to this section.
(d)
An insurer, nonprofit health service plan, or health maintenance organization may require a group policyholder that requests coverage for a domestic partner or child dependent of the domestic partner of an insured under subsection (c)(2) of this section to provide proof of the eligibility of the domestic partner or child dependent of the domestic partner for coverage under this section.
(e)
The Commissioner shall adopt regulations to implement this section.
Md. Code Ann., Ins. § 15-404 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–404LinkCopy Citation
(a)
This section applies to:
(1)
each group or blanket health insurance policy that is issued or delivered in the State and provides coverage on an expense-incurred basis; and
(2)
each group medical or major medical contract or certificate that is issued or delivered in the State by a nonprofit health service plan.
(b)
Each policy, contract, or certificate subject to this section shall provide a benefit that allows the addition of a certificate holder’s or subscriber’s dependent children to the certificate holder’s or subscriber’s policy or contract at any time and without evidence of insurability if:
(1)
the dependent children previously were covered under the policy or contract of the certificate holder’s or subscriber’s spouse; and
(2)
the certificate holder’s or subscriber’s spouse has died.
(c)
This section applies regardless of whether a certificate holder’s or subscriber’s dependent children are eligible for any continuation or conversion privileges under the policy or contract of the certificate holder’s or subscriber’s spouse.
(d)
Within 6 months after the death of the spouse, the certificate holder or subscriber must exercise the benefit provided under this section.
Md. Code Ann., Ins. § 15-405 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–405LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer that holds a certificate of authority in the State and provides health insurance in the State;
(ii)
a health maintenance organization that is licensed to operate in the State; or
(iii)
a nonprofit health service plan that is licensed to operate in the State.
(3)
“Health insurance coverage” means health care coverage under which medical care services can be provided to a child.
(4)
“Insuring parent” means a parent who:
(i)
is required under a court or administrative order to provide health insurance coverage for a child; or
(ii)
otherwise provides health insurance coverage for a child.
(5)
“Medical support notice” means a notice that is:
(i)
in a format prescribed by federal law; and
(ii)
issued by a child support agency to enforce the health insurance coverage provisions of a child support order.
(6)
“Order” means a ruling that:
(i)
is issued by a court of this State or another state or an administrative agency of another state; and
(ii)
(1)
creates or recognizes the right of a child to receive benefits under a parent’s health insurance coverage; or
(2)
establishes a parent’s obligation to pay child support and provide health insurance coverage for a child.
(7)
“Qualified medical support order” means a medical child support order issued under State law that complies with § 609(a) of the Employee Retirement Income Security Act of 1974 (ERISA).
(b)
This section applies to:
(1)
insurers, nonprofit health service plans, and health maintenance organizations that operate in the State under a certificate of authority;
(2)
group health plans, as defined in § 607(1) of the Employee Retirement Income Security Act of 1974 (ERISA); and
(3)
persons that offer a service benefit plan, as defined in federal law.
(c)
If a parent eligible for family members’ coverage is required under an order to provide health insurance coverage for a child, an entity subject to this section:
(1)
shall allow the insuring parent to enroll in family members’ coverage and include the child in that coverage regardless of enrollment period restrictions;
(2)
if the insuring parent is enrolled in health insurance coverage but does not include the child in the enrollment, shall:
(i)
allow the noninsuring parent, child support enforcement agency, or Maryland Department of Health to apply for enrollment on behalf of the child; and
(ii)
include the child in the coverage regardless of enrollment period restrictions; and
(3)
may not terminate health insurance coverage for the child unless written evidence is provided to the entity that:
(i)
the order is no longer in effect;
(ii)
the child has been or will be enrolled under other reasonable health insurance coverage that will take effect on or before the effective date of the termination;
(iii)
the employer has eliminated family members’ coverage for all of its employees; or
(iv)
the employer no longer employs the insuring parent, except that if the parent elects to exercise the provisions of the federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), coverage shall be provided for the child consistent with the employer’s plan for postemployment health insurance coverage for dependents.
(d)
Notwithstanding any other provision of this article, an entity subject to this section may not deny enrollment of a child under the health insurance coverage of an insuring parent because the child:
(1)
was born out of wedlock;
(2)
is not claimed as a dependent on the insuring parent’s federal income tax return;
(3)
does not reside with the insuring parent or in the service area of the entity; or
(4)
is receiving benefits or is eligible to receive benefits under the Maryland Medical Assistance Program.
(e)
If a child has health insurance coverage through an insuring parent, an entity subject to this section shall:
(1)
provide to the noninsuring parent membership cards, claims forms, and any other information necessary for the child to obtain benefits through the health insurance coverage; and
(2)
process the claims forms and make appropriate payment to the noninsuring parent, health care provider, or Maryland Department of Health if the noninsuring parent incurs expenses for health care provided to the child.
(f)
Within 20 business days after receipt of a medical support notice from an employer, the carrier:
(1)
shall determine whether the medical support notice contains:
(i)
the employee’s name and mailing address; and
(ii)
the child’s name and the child’s mailing address or the address of a substituted official;
(2)
if the medical support notice does not contain the information described in paragraph (1) of this subsection, shall complete and forward the appropriate part of the medical support notice to the issuing child support enforcement agency advising that the medical support notice does not constitute a qualified medical child support order; and
(3)
if the medical support notice contains the information described in paragraph (1) of this subsection, shall comply with the following requirements:
(i)
determine the child’s eligibility for enrollment;
(ii)
complete and send the appropriate part of the medical support notice to the employer and the Child Support Administration;
(iii)
enroll the child if the child is eligible for enrollment, subject to subsection (g) of this section;
(iv)
send to the employee, child, and custodial parent of the child a written notice that explains that the coverage of the child is or will become available to the child; and
(v)
send to the custodial parent of the child a written description of:
(1)
the health insurance coverage;
(2)
the effective date of coverage;
(3)
the employee’s cost for the health insurance coverage; and
(4)
if not already provided:
(A)
a summary plan description;
(B)
any forms, documents, or information necessary to effectuate coverage; and
(C)
any information necessary to submit claims for benefits.
(g)
If the employee’s eligibility for health insurance coverage is subject to a waiting period that has not been completed, the carrier:
(1)
shall complete and send the appropriate part of the medical support notice to the employer and the issuing child support agency within 20 business days after receipt of the medical support notice from the employer; and
(2)
on the employee’s satisfaction of the waiting period, shall complete enrollment of the child in accordance with this section and send the notice and information required under subsection (f)(3) of this section.
(h)
If the employee’s health insurance plan requires that the employee be enrolled in order for the child to be enrolled and the employee is not currently enrolled, the carrier shall enroll both the employee and the child, without regard to enrollment period restrictions, within the time period specified in subsection (f) of this section.
(i)
If a child is eligible for enrollment, the carrier shall complete the enrollment without regard to enrollment period restrictions, within the time periods specified in subsections (f) and (g) of this section.
(j)
The requirement for notification of the child under subsection (f)(3)(iv) of this section may be satisfied by notifying the custodial parent if the child and the custodial parent live at the same address.
Md. Code Ann., Ins. § 15-406 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–406LinkCopy Citation
(a)
In this section, “health insurance coverage” means health care coverage under which medical care services can be provided to a child.
(b)
This section applies to:
(1)
commercial insurers, nonprofit health service plans, and health maintenance organizations that operate in the State under a certificate of authority;
(2)
group health plans, as defined in § 607(1) of the Employee Retirement Income Security Act of 1974 (ERISA); and
(3)
persons that offer a service benefit plan, as defined in federal law.
(c)
An entity subject to this section may not consider whether an individual is eligible for or receives medical assistance from this State or another state under 42 U.S.C. § 1396a when:
(1)
determining the eligibility of the individual for enrollment in health insurance coverage; or
(2)
calculating any payments for benefits for which the individual is eligible under the health insurance coverage.
(d)
On presentation of a claim, an entity subject to this section shall reimburse the State to the extent that:
(1)
the State has paid for expenses for health care services that are provided to an eligible individual and covered under the Maryland Medical Assistance Program; and
(2)
those health care services are included under the individual’s health insurance coverage provided by the entity.
(e)
If a State agency has been assigned the rights of an individual who is eligible for medical assistance and who has health insurance coverage provided by an entity subject to this section, the entity may not impose on the State agency requirements that are different from the requirements that apply to an insurance producer, assignee, or any other individual who has health insurance coverage provided by the entity.
Md. Code Ann., Ins. § 15-407 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–407LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Dependent child” means a child of the insured who:
(i)
was covered under a group contract as a qualified or eligible dependent of the insured immediately before the death of the insured; or
(ii)
was born to a qualified secondary beneficiary defined in paragraph (5)(i) of this subsection after the death of the insured.
(3)
“Group contract” means:
(i)
an insurance contract or policy that is issued or delivered in the State to the employer of the insured by an insurer or nonprofit health service plan and that provides group hospital, medical, or surgical benefits to the employees of the employer on an expense–incurred basis; or
(ii)
a contract between the employer of the insured and a health maintenance organization certified under Title 19, Subtitle 7 of the Health – General Article that provides hospital, medical, or surgical benefits to the employees of the employer.
(4)
“Insured” means an employee who is a resident of the State and covered under a current or predecessor group contract with the same employer for at least 3 months before death.
(5)
“Qualified secondary beneficiary” means an individual who is:
(i)
a beneficiary under the group contract as the spouse of the insured for at least 30 days immediately preceding the death of the insured; or
(ii)
a dependent child of the insured.
(b)
(1)
Each group contract in force on the date of the death of the insured shall provide continuation coverage in accordance with this section.
(2)
Subject to subsection (c) of this section, if continuation coverage is elected by or on behalf of a qualified secondary beneficiary, the group contract shall provide continuation coverage to the qualified secondary beneficiary after the death of the insured.
(c)
Continuation coverage that is elected by or on behalf of a qualified secondary beneficiary under the group contract shall begin on the date of the death of the insured and end on the earliest of the following:
(1)
18 months after the date of the death of the insured;
(2)
the date on which the qualified secondary beneficiary fails to make timely payment of an amount required under subsection (d)(2) of this section;
(3)
the date on which the qualified secondary beneficiary becomes eligible for hospital, medical, or surgical benefits under an insured or self–insured group health benefit program or plan, other than the group contract, that is written on an expense–incurred basis or is with a health maintenance organization;
(4)
the date on which the qualified secondary beneficiary becomes entitled to benefits under Title XVIII of the Social Security Act;
(5)
the date on which the qualified secondary beneficiary accepts hospital, medical, or surgical coverage under a nongroup contract or policy that is written on an expense–incurred basis or is with a health maintenance organization;
(6)
the date on which the qualified secondary beneficiary elects to terminate coverage under the group contract;
(7)
the date on which the employer ceases to provide benefits to its employees under a group contract; or
(8)
for an individual who is a qualified secondary beneficiary by reason of having been a dependent child, the date on which the individual would no longer be covered under the group contract if the insured had not died.
(d)
Continuation coverage under this section shall:
(1)
be provided without evidence of insurability or additional waiting periods;
(2)
require the qualified secondary beneficiary to pay to the employer an amount that does not exceed:
(i)
the sum of the employer contribution and any contribution that the insured would have been required to pay if the insured had not died; and
(ii)
a reasonable administrative fee that is subject to review and approval by the Commissioner;
(3)
allow the payment of the amount specified in paragraph (2) of this subsection in monthly installments if the qualified secondary beneficiary elects to do so; and
(4)
be identical to the coverage offered under the group contract to similarly situated individuals for whom there has not been a death of the insured.
(e)
(1)
To elect continuation coverage provided under this section, a qualified secondary beneficiary or authorized representative shall submit a signed election notification form to the insured’s employer during the election period.
(2)
The election period for continuation coverage under this section begins on the date of the death of the insured and ends at least 45 days after that date.
(3)
Within 14 days after receipt of a request for an election notification form, the employer shall deliver or send by first–class mail the election notification form to the qualified secondary beneficiary or authorized representative.
(f)
Each certificate issued to an insured under a group contract shall include a statement, in a manner and form approved by the Commissioner, that advises the insured of the following:
(1)
the availability of continuation coverage under this section;
(2)
a summary of the eligibility for and duration of the continuation coverage; and
(3)
the procedure for making an election to receive continuation coverage if the insured dies.
(g)
The Commissioner shall:
(1)
publish at least annually in the Maryland Register and in a newspaper of general circulation in each county notice that describes the continuation coverage required under this section;
(2)
prescribe by regulation the form and content of the election notification form; and
(3)
make election notification forms available to each employer whose employees are covered by a group contract.
(h)
Notice of the availability of continuation coverage under this section shall be provided by:
(1)
the Secretary of Health as specified in § 4–217 of the Health – General Article; and
(2)
licensed funeral directors as specified in § 7–407 of the Health Occupations Article.
(i)
An employer that fails to provide notice or an election notification form under this section is not liable to a qualified secondary beneficiary or the insured for benefits that otherwise would have been payable or for other damages that result from the failure to provide the notice or form.
(j)
An employer that terminates continuation coverage after notice or nonpayment of an amount required under subsection (d)(2) of this section by a qualified secondary beneficiary, or an insurer that terminates continuation coverage after notice by the employer, is not liable to a qualified secondary beneficiary for benefits that otherwise would have been payable under this section if the termination:
(1)
is made in good faith;
(2)
is reasonable under the circumstances; and
(3)
is not the result of a mutual or material mistake of fact.
(k)
This section does not affect or limit the right of a qualified secondary beneficiary to conversion privileges under a group contract.
Md. Code Ann., Ins. § 15-408 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–408LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Change in status” means the divorce of the insured and the insured’s spouse.
(3)
“Dependent child” means a child of the insured who:
(i)
was covered under a group contract as a qualified or eligible dependent of the insured immediately before the change in status; or
(ii)
was born to a qualified secondary beneficiary defined in paragraph (6)(i) of this subsection after the change in status.
(4)
“Group contract” means:
(i)
an insurance contract or policy that is issued or delivered in the State to the employer of the insured by an insurer or nonprofit health service plan and that provides group hospital, medical, or surgical benefits to the insured on an expense-incurred basis; or
(ii)
a contract between the employer of the insured and a health maintenance organization certified under Title 19, Subtitle 7 of the Health - General Article that provides group hospital, medical, or surgical benefits offered to the insured.
(5)
“Insured” means an employee who is a resident of the State and covered under a group contract.
(6)
“Qualified secondary beneficiary” means an individual who is:
(i)
a beneficiary under the group contract as the spouse of the insured for at least 30 days immediately preceding the change in status; or
(ii)
a dependent child of the insured.
(7)
“Termination statement” means written notice of an event specified in subsection (c) of this section that is:
(i)
provided to the employer on a form that the Commissioner prescribes; and
(ii)
(1)
signed by the insured and a qualified secondary beneficiary defined in paragraph (6)(i) of this subsection; or
(2)
accompanied by the insured’s signed and sworn affidavit that verifies all facts in the termination statement.
(b)
(1)
Each group contract in force on the date of the change in status shall provide continuation coverage in accordance with this section.
(2)
Subject to subsection (c) of this section, a qualified secondary beneficiary is entitled to continuation coverage under a group contract after a change in status.
(3)
Paragraph (2) of this subsection does not apply while the insured is not covered by a group contract.
(c)
Continuation coverage under this section shall begin on the date of the change in status and end on the earliest of the following:
(1)
the date on which the qualified secondary beneficiary becomes eligible for hospital, medical, or surgical benefits under an insured or self-insured group health benefit program or plan, other than the group contract, that is written on an expense-incurred basis or is with a health maintenance organization;
(2)
the date on which the qualified secondary beneficiary becomes entitled to benefits under Title XVIII of the Social Security Act;
(3)
the date on which the qualified secondary beneficiary accepts hospital, medical, or surgical coverage under a nongroup contract or policy that is written on an expense-incurred basis or is with a health maintenance organization;
(4)
the date on which the qualified secondary beneficiary elects to terminate coverage under the group contract;
(5)
for an individual who is a qualified secondary beneficiary by reason of having been a dependent child, the date on which the individual would no longer be covered under the group contract if there had not been a change in status; or
(6)
for an individual who is a qualified secondary beneficiary by reason of having been the insured’s spouse, the date on which the individual remarries.
(d)
Continuation coverage under this section shall be identical to the coverage offered under the group contract to similarly situated beneficiaries for whom there has not been a change in status.
(e)
(1)
From the date of the change in status until the date on which a termination statement is received by the employer, the insured shall pay to the employer, through payroll deduction or otherwise as determined by the employer, the sum of the employer’s contribution for a qualified secondary beneficiary defined in subsection (a)(6)(i) of this section and the amount of contribution that would have been paid by the insured if there had not been a change in status.
(2)
The additional costs payable by the insured under paragraph (1) of this subsection may be allocated between the insured and a qualified secondary beneficiary who was the insured’s spouse or may be reimbursed in full to the insured by the qualified secondary beneficiary by agreement between the parties or, as equity may require, by court order under Title 10, Title 11, or Title 12 of the Family Law Article at the time of the change in status or after the change in status.
(f)
Each certificate issued to an insured under a group contract shall include a statement, in a manner and form approved by the Commissioner, that advises the insured of the following:
(1)
the availability of continuation coverage under this section; and
(2)
a summary of the eligibility for and duration of the continuation coverage.
(g)
The Commissioner shall:
(1)
publish at least annually in the Maryland Register and in a newspaper of general circulation in each county notice that describes the continuation coverage required under this section;
(2)
prescribe by regulation the form and content of the termination statement; and
(3)
make termination statement forms available to each employer whose employees are covered by a group contract.
(h)
(1)
On request of a qualified secondary beneficiary, from the date of the change in status until the date on which a termination statement is received by the employer, the employer shall make available to the qualified secondary beneficiary forms for submitting claims to the group contract insurer.
(2)
On presentation of a divorce decree by a qualified secondary beneficiary, the group contract insurer may reimburse the qualified secondary beneficiary directly for hospital, medical, or surgical expenses that the qualified secondary beneficiary has paid.
(3)
A group contract insurer that reimburses a qualified secondary beneficiary in accordance with this subsection is not liable to any other party for payment for the same services.
(4)
If the insured receives reimbursement from the group contract insurer for hospital, medical, or surgical expenses that a qualified secondary beneficiary has paid, the insured immediately shall pay the reimbursement to the qualified secondary beneficiary unless a written agreement or court order provides otherwise.
(i)
(1)
An employer that terminates continuation coverage after notice by the insured or qualified secondary beneficiary, or an insurer that terminates continuation coverage after notice by the employer, is not liable to the insured or qualified secondary beneficiary for benefits that otherwise would have been payable under this section if the termination:
(i)
is made in good faith;
(ii)
is reasonable under the circumstances; and
(iii)
is not the result of a mutual or material mistake of fact.
(2)
Notwithstanding paragraph (1) of this subsection, receipt by the employer of a termination statement is conclusive evidence of termination, and neither the employer nor the insurer is liable to the qualified secondary beneficiary or insured for benefits that otherwise would have been payable under this section.
(j)
This section does not affect or limit the right of a qualified secondary beneficiary to conversion privileges under a group contract.
Md. Code Ann., Ins. § 15-409 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–409LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Change in status” means the termination of the insured’s employment other than for cause.
(ii)
“Change in status” includes:
(1)
involuntary termination of the insured’s employment other than for cause; and
(2)
voluntary termination of the insured’s employment by the insured employee.
(3)
“Group contract” means:
(i)
an insurance contract or policy that is issued or delivered in the State to the employer of the insured by an insurer or nonprofit health service plan and that provides group hospital, medical, or surgical benefits to the employees of the employer on an expense–incurred basis; or
(ii)
a contract between the employer of an insured and a health maintenance organization certified under Title 19, Subtitle 7 of the Health – General Article that provides group hospital, medical, or surgical benefits to the employees of the employer.
(4)
“Insured” means an employee who is a resident of the State and covered under a current or predecessor group contract with the same employer for at least 3 months before the change in status.
(b)
(1)
Each group contract in force on the date of the change in status shall provide continuation coverage in accordance with this section.
(2)
Subject to subsection (c) of this section, if continuation coverage is elected by or on behalf of an insured, the group contract shall provide continuation coverage to the insured after a change in status.
(c)
Continuation coverage that is elected by or on behalf of the insured under the group contract shall begin on the date of the change in status and end on the earliest of the following:
(1)
18 months after the date of the change in status;
(2)
the date on which the insured fails to make timely payment of an amount required under subsection (d)(2) of this section;
(3)
the date on which the insured becomes eligible for hospital, medical, or surgical benefits under an insured or self–insured group health benefit program or plan, other than the group contract, that is written on an expense–incurred basis or is with a health maintenance organization;
(4)
the date on which the insured becomes entitled to benefits under Title XVIII of the Social Security Act;
(5)
the date on which the insured accepts hospital, medical, or surgical coverage under a nongroup contract or policy that is written on an expense–incurred basis or is with a health maintenance organization;
(6)
the date on which the insured elects to terminate coverage under the group contract; or
(7)
the date on which the employer ceases to provide benefits to its employees under a group contract.
(d)
Continuation coverage under this section shall:
(1)
be provided without evidence of insurability or additional waiting periods;
(2)
require the insured to pay to the employer an amount that does not exceed:
(i)
the sum of the employer contribution and any contribution that the insured would have been required to pay if there had not been a change in status; and
(ii)
a reasonable administrative fee that is subject to review and approval by the Commissioner;
(3)
allow the payment of the amount specified in item (2) of this subsection in monthly installments if the insured elects to do so;
(4)
be identical to the coverage offered under the group contract to similarly situated individuals for whom there has not been a change in status; and
(5)
be available to the spouse and dependent children of the insured if:
(i)
the group contract provides benefits for spouses and dependent children; and
(ii)
the insured’s spouse and dependent children were covered under the group contract before the change in status.
(e)
(1)
To elect continuation coverage provided under this section, an insured or authorized representative shall submit a signed election notification form to the insured’s employer during the election period.
(2)
The election period for continuation coverage under this section begins on the date of the change in status and ends at least 45 days after that date.
(3)
Within 14 days after receipt of a request for an election notification form, the employer shall deliver or send by first–class mail the election notification form to the insured or authorized representative.
(f)
Each certificate issued to an insured under a group contract shall include a statement, in a manner and form approved by the Commissioner, that advises the insured of the following:
(1)
the availability of continuation coverage under this section;
(2)
a summary of the eligibility for and duration of the continuation coverage; and
(3)
the procedure for making an election to receive continuation coverage if a change in status occurs.
(g)
The Commissioner shall:
(1)
publish at least annually in the Maryland Register and in a newspaper of general circulation in each county notice that describes the continuation coverage required under this section;
(2)
prescribe by regulation the form and content of the election notification form; and
(3)
make election notification forms available to each employer whose employees are covered by a group contract.
(h)
Notice of the availability of continuation coverage under this section shall be provided by:
(1)
the employer; and
(2)
the Secretary of Labor as specified in § 8–805(c) of the Labor and Employment Article.
(i)
An employer that fails to provide notice or an election notification form under this section is not liable to the insured or any other covered individual for benefits that otherwise would have been payable or for other damages that result from the failure to provide the notice or form.
(j)
An employer that terminates continuation coverage after notice or nonpayment of an amount required under subsection (d)(2) of this section by the insured or other covered individual, or an insurer that terminates continuation coverage after notice by the employer, is not liable to the insured or other covered individual for benefits that otherwise would have been payable under this section if the termination:
(1)
is made in good faith;
(2)
is reasonable under the circumstances; and
(3)
is not the result of a mutual or material mistake of fact.
(k)
This section does not affect or limit the right of an insured to conversion privileges under a group contract.
Md. Code Ann., Ins. § 15-409.1 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–409.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Act” means the federal American Recovery and Reinvestment Act of 2009 (P.L. 111–5).
(3)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan; or
(iii)
a health maintenance organization.
(4)
“Small employer” has the meaning stated in § 15–1201 of this title.
(b)
This section applies to a carrier that issues health benefit plans to small employers in accordance with Subtitle 12 of this title.
(c)
A carrier shall allow an extended election period for continuation coverage under § 15–409 of this subtitle if the individual:
(1)
was involuntarily terminated from employment by a small employer between September 1, 2008, and February 16, 2009, inclusive, as described in § 3001(a)(3)(C) of the Act;
(2)
is an assistance eligible individual, as defined in § 3001(a)(3) of the Act, or would be an assistance eligible individual if an election of continuation coverage under § 15–409 of this subtitle was in effect on the date of enactment of the Act; and
(3)
was eligible for continuation coverage under § 15–409 of this subtitle at the time of the individual’s termination of employment.
(d)
The extended election period provided under this section shall continue until 60 days after provision of the notification required by § 3001(a)(7)(C) of the Act if the notification describes the extended election period required under this section.
(e)
Any continuation coverage elected by an individual during an extended election period under this section:
(1)
shall begin during the first period of coverage beginning on or after the individual’s election of continuation coverage; and
(2)
may not extend beyond the period of continuation coverage that would have been required under § 15–409 of this subtitle if the coverage had been elected as required under that section.
Md. Code Ann., Ins. § 15-411 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–411LinkCopy Citation
(a)
Each group health insurance contract or policy that is issued by an insurer or nonprofit health service plan shall provide continuous open enrollment for the purpose of allowing a married employee who is enrolled under the contract or policy to alter the terms of the employee’s coverage to include the employee’s spouse or children if the employee’s spouse loses coverage under another group health insurance contract or policy because of the involuntary termination of the spouse’s employment other than for cause.
(b)
A group health insurance contract or policy may not require evidence of insurability for a spouse who qualifies for group health insurance coverage under this section.
(c)
A married employee who wishes to alter the terms of the employee’s coverage under this section shall notify the employer within 6 months after the date on which the coverage of the employee’s spouse under another group health insurance contract or policy terminates.
Md. Code Ann., Ins. § 15-413 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–413LinkCopy Citation
(a)
(1)
Except as provided in paragraph (2) of this subsection, this section applies to each group health insurance policy that:
(i)
(1)
is issued or delivered in the State;
(2)
is issued to a policyholder that is incorporated or has a main office in the State; or
(3)
covers individuals who reside or work in the State; and
(ii)
provides benefits in the event of the disability of an individual covered under the policy.
(2)
This section does not apply to:
(i)
a policy issued under Title 13 of this article if the insurance under the policy is terminated because of the prepayment or refinancing, wholly or partly, with the same creditor of a prior debt; or
(ii)
except as the Commissioner provides by regulation, a group policy issued to an employer to cover its employees.
(b)
Each group policy subject to this section shall provide that a covered individual whose coverage under the group policy is terminated for any reason other than failure of the covered individual to pay a required premium or contribution is entitled, without evidence of insurability, to an individual policy of disability income insurance.
(c)
By regulation the Commissioner may exempt from the requirements of this section certain types of group policies that the Commissioner considers appropriate.
(d)
(1)
An individual policy issued under this section shall take effect immediately after the termination of coverage under the group policy if the covered individual:
(i)
makes a timely written request for an individual policy; and
(ii)
pays the first premium for the individual policy.
(2)
By regulation the Commissioner shall establish rules to determine when a written request and payment of the required premium are timely.
(e)
An individual policy issued under this section shall be guaranteed renewable for the term or to the limiting age for which benefits would have been provided if coverage under the group policy had not terminated.
(f)
The level of benefits under an individual policy issued under this section shall equal approximately the disability benefits that would have been provided if coverage under the group policy had not terminated.
(g)
(1)
The premium for an individual policy issued under this section shall be determined in accordance with the insurer’s table of premium rates that is applicable to the attained age and class of risk of the covered individual for the type and amount of insurance provided.
(2)
The insurer shall reserve the right to change the premium on any policy anniversary subject to approval by the Commissioner.
(h)
The Commissioner may establish requirements that govern notification by the insurer or group policyholder to the individual whose coverage under the group policy is being terminated of the right of conversion to an individual policy.
(i)
The insurer may limit the right of conversion to individuals who have been covered under the group policy for at least 1 year.
(j)
Each group health insurance policy that was issued before January 1, 1984, shall be amended to comply with the requirements of this section on the first policy renewal anniversary date on or after January 1, 1984.
Md. Code Ann., Ins. § 15-416 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–416LinkCopy Citation
(a)
This section applies to insurers, nonprofit health service plans, and health maintenance organizations that deliver or issue for delivery in the State individual, group, or blanket health insurance policies and contracts.
(b)
At least 60 days before a child who is covered under a parent’s individual, group, or blanket health insurance policy or contract reaches the limiting age under the policy or contract, an entity subject to this section shall:
(1)
notify the parent of criteria under which a child may remain eligible for coverage as a dependent under the policy or contract; and
(2)
provide information regarding:
(i)
any other policies that may be available to the child from the entity; and
(ii)
the availability of additional information from the Administration regarding individual policies in the State.
(c)
The Commissioner shall establish and publish by bulletin the notice to be given under this section.
Md. Code Ann., Ins. § 15-417 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–417LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section that provides health benefits to full-time students over the age of 18 may not exclude health benefits for a student over the age of 18 who:
(1)
is enrolled less than full time as a result of a documented disability that prevents the student from maintaining a full-time course load; and
(2)
is maintaining a course load of at least 7 credit hours per semester.
(c)
An entity subject to this section may require the insured, subscriber, or enrollee to provide verification of the disability from a disability services professional employed by the institution of higher education that the student attends or a health care provider with special expertise in and knowledge of the disability.
Md. Code Ann., Ins. § 15-418 (2026)
Title 15. Health Insurance
Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies
§ 15–418LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan; or
(iii)
a health maintenance organization.
(3)
“Child dependent” means an individual who:
(i)
is:
(1)
the grandchild of the insured; or
(2)
a child who is entitled to dependent coverage under § 15–403.1 of this subtitle;
(ii)
is unmarried; and
(iii)
is under the age of 25 years.
(b)
(1)
This section applies to:
(i)
each policy of individual or group health insurance that is issued in the State;
(ii)
each contract that is issued in the State by a nonprofit health service plan; and
(iii)
each contract that is issued in the State by a health maintenance organization.
(2)
Notwithstanding paragraph (1) of this subsection, this section does not apply to:
(i)
a contract covering one or more, or any combination of the following:
(1)
coverage only for loss caused by an accident;
(2)
disability coverage;
(3)
credit–only insurance; or
(4)
long–term care coverage; or
(ii)
the following benefits if they are provided under a separate contract:
(1)
dental coverage;
(2)
vision coverage;
(3)
Medicare supplement insurance;
(4)
coverage limited to benefits for a specified disease or diseases;
(5)
travel accident or sickness coverage; and
(6)
fixed indemnity limited benefit insurance that does not provide benefits on an expense incurred basis.
(c)
Each policy or contract subject to this section that provides coverage for dependents shall:
(1)
include coverage for a child dependent;
(2)
provide the same health insurance benefits to a child dependent that are available to any other covered dependent; and
(3)
provide health insurance benefits to a child dependent at the same rate or premium applicable to any other covered dependent.
(d)
This section does not limit or alter any right to dependent coverage or to the continuation of coverage that is otherwise provided for in this article.
Subtitle 5. Prohibited Denials, Exclusions, and Reductions of Coverage
Md. Code Ann., Ins. § 15-501 (2026)
Title 15. Health Insurance
Subtitle 5. Prohibited Denials, Exclusions, and Reductions of Coverage
§ 15–501LinkCopy Citation
An individual, group, or blanket health insurance contract may not contain a provision that reduces payments to an individual entitled to receive disability payments under the contract because the individual receives an increase in Social Security payments.
Md. Code Ann., Ins. § 15-502 (2026)
Title 15. Health Insurance
Subtitle 5. Prohibited Denials, Exclusions, and Reductions of Coverage
§ 15–502LinkCopy Citation
(a)
This section applies to each individual or group policy or certificate of health insurance or automobile insurance that is:
(1)
delivered or issued for delivery in the State by an insurer or nonprofit health service plan; and
(2)
issued, renewed, amended, or reissued on or after July 1, 1978.
(b)
A policy or certificate subject to this section that provides or pays for health care benefits may not contain a provision that denies or reduces benefits because services are rendered to a policyholder, certificate holder, or beneficiary who is eligible for or receives medical assistance under § 15-103 of the Health - General Article.
Md. Code Ann., Ins. § 15-503 (2026)
Title 15. Health Insurance
Subtitle 5. Prohibited Denials, Exclusions, and Reductions of Coverage
§ 15–503LinkCopy Citation
An insurer or nonprofit health service plan may not deny, cancel, or refuse to renew an individual, group, or blanket health insurance policy solely because the insured has been exposed to diethylstilbestrol, commonly known as DES.
Md. Code Ann., Ins. § 15-505 (2026)
Title 15. Health Insurance
Subtitle 5. Prohibited Denials, Exclusions, and Reductions of Coverage
§ 15–505LinkCopy Citation
(a)
This section applies to each individual, group, or blanket health insurance policy or certificate that is issued by an insurer or nonprofit health service plan on or after July 2, 1970, covering a person in the State.
(b)
(1)
A policy or certificate subject to this section that provides coverage for disability or sickness while an individual is confined at home may not exclude payments or benefits because the individual leaves home for medical treatment.
(2)
Coverage extends to individuals confined at home, who are otherwise eligible, regardless of the place of medical treatment.
Md. Code Ann., Ins. § 15-506 (2026)
Title 15. Health Insurance
Subtitle 5. Prohibited Denials, Exclusions, and Reductions of Coverage
§ 15–506LinkCopy Citation
(a)
Each insurer and nonprofit health service plan that provides maternity benefits in a policy form customarily issued on an individual or family basis shall offer the benefits to individuals regardless of marital status.
(b)
(1)
This subsection applies to each group or blanket health insurance policy that is delivered or issued for delivery in the State by an insurer or nonprofit health service plan.
(2)
Each policy subject to this subsection that provides maternity benefits for pregnancy and childbirth of employees or members or of covered dependents of employees or members, whether the benefits are in the form of disability, hospital, medical, or surgical benefits, shall provide identical benefits regardless of marital status to:
(i)
all covered employees or members; or
(ii)
all covered employees or members and all covered dependents of employees or members.
Md. Code Ann., Ins. § 15-508.1 (2026)
Title 15. Health Insurance
Subtitle 5. Prohibited Denials, Exclusions, and Reductions of Coverage
§ 15–508.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means an insurer or a nonprofit health service plan.
(3)
“Exclusionary rider” means an endorsement to an individual health benefit plan that excludes benefits for one or more named conditions that are discovered by a carrier during the underwriting process.
(4)
“Health benefit plan” has the meaning stated in § 15–1301 of this title.
(5)
“Individual health benefit plan” means a health benefit plan issued by a carrier that insures:
(i)
only one individual; or
(ii)
one individual and one or more family members of the individual.
(b)
This section applies to individual health benefit plans that are issued or delivered in the State before March 23, 2010.
(c)
A carrier may not attach an exclusionary rider to an individual health benefit plan unless the carrier obtains the prior written consent of the policyholder.
(d)
A carrier may impose a preexisting condition exclusion or limitation on an individual for a condition that was not discovered during the underwriting process for an individual health benefit plan only if the exclusion or limitation:
(1)
relates to a condition of the individual, regardless of its cause, for which medical advice, diagnosis, care, or treatment was recommended or received within the 12–month period immediately preceding the effective date of the individual’s coverage; and
(2)
extends for a period of not more than 12 months after the effective date of the individual’s coverage.
Md. Code Ann., Ins. § 15-509 (2026)
Title 15. Health Insurance
Subtitle 5. Prohibited Denials, Exclusions, and Reductions of Coverage
§ 15–509LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Activity–only wellness program” means a type of health–contingent wellness program in which an individual is required to perform or complete an activity related to a health factor in order to obtain a reward, but which does not require the individual to attain or maintain a specific health outcome.
(3)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan; or
(iii)
a health maintenance organization.
(4)
“Grandfathered health benefit plan” has the meaning stated in § 1251 of the Affordable Care Act.
(5)
“Health benefit plan” has the meaning stated in § 15–1301 of this title.
(6)
(i)
“Health–contingent wellness program” means a program that requires an individual to satisfy a standard related to a health factor to obtain a reward.
(ii)
“Health–contingent wellness program” includes:
(1)
an activity–only wellness program; and
(2)
an outcome–based wellness program.
(7)
“Health factor” means, in relation to an individual, any of the following health status–related factors:
(i)
health status;
(ii)
medical condition;
(iii)
claims experience;
(iv)
receipt of health care;
(v)
medical history;
(vi)
genetic information;
(vii)
evidence of insurability;
(viii)
disability; or
(ix)
any other health status–related factor determined appropriate by the U.S. Secretary of Health and Human Services.
(8)
“Incentive” means:
(i)
a discount of a premium or contribution;
(ii)
a waiver of all or part of a cost–sharing mechanism, such as deductibles, copayments, or coinsurance;
(iii)
the absence of a surcharge;
(iv)
the value of a benefit that otherwise would not be provided under the policy or contract; or
(v)
a rebate as permitted under § 27–210 of this article.
(9)
“Outcome–based wellness program” means a type of health–contingent wellness program in which an individual must attain or maintain a specific health outcome in order to obtain a reward.
(10)
“Participatory wellness program” means a program that does not:
(i)
provide a reward; or
(ii)
include any conditions for obtaining a reward that are based on an individual satisfying a standard that is related to a health factor.
(11)
“Reward” means:
(i)
obtaining an incentive; or
(ii)
avoiding a penalty.
(b)
This section applies to grandfathered and nongrandfathered individual and group health benefit plans.
(c)
(1)
A carrier may include a participatory wellness program as part of an individual or group health benefit plan.
(2)
A participatory wellness program shall be made available to all similarly situated individuals regardless of health status.
(d)
A carrier may condition a reward for an activity–only wellness program in a group health benefit plan if:
(1)
the activity–only wellness program provides individuals with an opportunity to qualify for the reward at least once a year;
(2)
the reward for the activity–only wellness program, together with the reward for other health–contingent wellness programs with respect to the health benefit plan, does not exceed:
(i)
30% of the total cost of employee–only coverage under the health benefit plan, except that the applicable percentage is increased by an additional 20 percentage points to the extent that the additional percentage is in connection with a program designed to prevent or reduce tobacco use; or
(ii)
when the plan provides coverage for family members, and when family members are permitted to participate in the activity–only wellness program, 30% of the cost of the coverage in which the family members are enrolled, except that the applicable percentage is increased by an additional 20 percentage points to the extent that the additional percentage is in connection with a program designed to prevent or reduce tobacco use;
(3)
the activity–only wellness program is reasonably designed to promote health or prevent disease;
(4)
the full reward under the activity–only wellness program is available to all similarly situated individuals; and
(5)
the carrier discloses the availability of a reasonable alternative standard to qualify for the reward in all plan materials describing the terms of an activity–only wellness program.
(e)
An activity–only wellness program shall be construed to be reasonably designed to promote health or prevent disease if the activity–only wellness program:
(1)
has a reasonable chance of improving the health of or preventing disease in participating individuals;
(2)
is not overly burdensome;
(3)
is not a subterfuge for discriminating based on a health factor;
(4)
is not highly suspect in the method chosen to promote health or prevent disease; and
(5)
provides a reasonable alternative standard to qualify for the reward for all individuals who do not meet the initial standard that is related to a health factor.
(f)
(1)
For an activity–only wellness program, a carrier shall provide a reasonable alternative standard for obtaining the reward for any individual who requests an alternative standard and for whom it is:
(i)
unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard; or
(ii)
medically inadvisable to attempt to satisfy the otherwise applicable standard.
(2)
A carrier may seek verification, such as a statement from an individual’s health care provider, that a health factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard, if reasonable under the circumstances.
(g)
(1)
A carrier may condition the reward for an outcome–based wellness program in a group health benefit plan if:
(i)
the outcome–based wellness program meets the requirements under subsections (d) and (e) of this section;
(ii)
the full reward is available to all similarly situated individuals; and
(iii)
an individual, on request, is provided with a reasonable alternative standard, provided that the individual does not meet the initial standard because of a medical condition or other health factor.
(2)
If the reasonable alternative standard is an educational program, the carrier:
(i)
shall make the educational program available or assist the individual in finding a program; and
(ii)
may not require an individual to pay for the cost of the educational program.
(3)
The time commitment required for the alternative standard shall be reasonable.
(4)
If the reasonable alternative is a diet program, the carrier is not required to pay for the cost of food, but is required to pay any membership or participation fee.
(5)
If the reasonable alternative standard is an activity–only wellness program, the reasonable alternative standard must comply with the requirements for activity–only wellness programs as if it were an initial program standard.
(6)
If the reasonable alternative standard is an outcome–based wellness program, the reasonable alternative standard must comply with the requirements for outcome–based wellness programs.
(7)
The reasonable alternative may not be a requirement to meet a different level of the same standard without additional time to comply that takes into account the individual’s circumstances.
(8)
An individual shall be given the opportunity to comply with the recommendations of the individual’s personal physician as a second reasonable alternative standard to meeting the reasonable alternative standard defined by the carrier, but only if the physician joins in the request.
(h)
A reward under an outcome–based wellness program is not available to all similarly situated individuals as required by subsection (g)(1)(ii) of this section unless the outcome–based wellness program allows a reasonable alternative standard, or waiver of the otherwise applicable standard, for obtaining the reward for any individual who does not meet the initial standard based on the measurement, test, or screening required by the outcome–based wellness program.
(i)
(1)
In determining if a carrier’s health–contingent wellness program meets the requirements of this section, the Commissioner may request a review of the health–contingent wellness program by an independent review organization selected from the list compiled under § 15–10A–05(b) of this title.
(2)
The expense of the review of the health–contingent wellness program by an independent review organization shall be paid by the carrier in the manner provided under § 15–10A–05(h) of this title.
Md. Code Ann., Ins. § 15-510 (2026)
Title 15. Health Insurance
Subtitle 5. Prohibited Denials, Exclusions, and Reductions of Coverage
§ 15–510LinkCopy Citation
No individual, group, or blanket insurance policy or contract issued or delivered in the State by an insurer, a nonprofit health service plan, or a health maintenance organization may deny a covered medically necessary behavioral health care service provided by a participating provider to a member who is a student solely on the basis that the service is provided at a public school or through a school–based health center under § 7–440 of the Education Article.
Subtitle 6. Required Reimbursement of Institutions
Md. Code Ann., Ins. § 15-601 (2026)
Title 15. Health Insurance
Subtitle 6. Required Reimbursement of Institutions
§ 15–601LinkCopy Citation
(a)
This section applies to insurers and nonprofit health service plans that provide hospital benefits in the State under individual, group, or blanket health insurance policies.
(b)
Each entity subject to this section that offers benefits to an insured or beneficiary who uses designated low-cost hospitals, that are different from the benefits offered when other hospitals are used, shall base its designation of a low-cost hospital on information that:
(1)
excludes the reasonable cost of medical education and of uncompensated care as determined by the Health Services Cost Review Commission;
(2)
excludes the cost associated with a shock trauma facility as determined by the Health Services Cost Review Commission;
(3)
excludes the amount in rates approved by the Health Services Cost Review Commission for undergraduate nursing education;
(4)
excludes from consideration each hospital that is determined by the Maryland Health Care Commission to be a sole community provider; and
(5)
compares hospitals on a regional basis, unless the entity demonstrates to the satisfaction of the Commissioner that a statewide comparison is more appropriate.
(c)
An entity subject to this section that provides hospital benefits under subsection (b) of this section may not subsidize those benefits from premiums earned by other benefit plans, programs, or policies.
Md. Code Ann., Ins. § 15-602 (2026)
Title 15. Health Insurance
Subtitle 6. Required Reimbursement of Institutions
§ 15–602LinkCopy Citation
(a)
This section applies to each individual, group, or blanket health insurance policy or certificate that is delivered or issued for delivery in the State by an insurer or nonprofit health service plan on or after July 2, 1969.
(b)
A policy or certificate subject to this section may not exclude payments or benefits for the treatment of tuberculosis, mental illness, or another illness covered under the policy or certificate because treatment is received in a hospital or other institution of the State or of a county or municipal corporation of the State, whether or not the hospital or other institution is deemed charitable.
Md. Code Ann., Ins. § 15-603 (2026)
Title 15. Health Insurance
Subtitle 6. Required Reimbursement of Institutions
§ 15–603LinkCopy Citation
(a)
If the Maryland Department of Health notifies an insurer or nonprofit health service plan that the Department has paid for or provided services to an individual who is covered under an individual, group, or blanket health insurance policy or contract that the insurer or nonprofit health service plan issued, delivered, or renewed in the State, the insurer or nonprofit health service plan shall reimburse the Department for the cost of the services, regardless of any provision in the health insurance policy or contract that requires payment to the policyholder, subscriber, or another payee.
(b)
(1)
The benefits payable to the Maryland Department of Health under this section are limited to those benefits available under the terms and conditions of the health insurance policy or contract for the services paid for or provided by the Department.
(2)
An insurer or nonprofit health service plan is not required to make payment to the Department under this section if, before receiving notice from the Department under subsection (a) of this section, the insurer or nonprofit health service plan has paid the benefits available under the health insurance policy or contract in good faith and in accordance with the terms and conditions of the policy or contract.
(c)
Notwithstanding any other provision of a health insurance policy, contract, or certificate, an insurer or nonprofit health service plan may not refuse to reimburse the Maryland Department of Health because of the manner, form, or date of a claim for reimbursement if, within 2 years after the date of the service for which reimbursement is sought, the Department provides to the insurer or nonprofit health service plan sufficient information to determine the liability of the insurer or nonprofit health service plan.
Md. Code Ann., Ins. § 15-604 (2026)
Title 15. Health Insurance
Subtitle 6. Required Reimbursement of Institutions
§ 15–604LinkCopy Citation
Each authorized insurer, nonprofit health service plan, and fraternal benefit society, and each managed care organization that is authorized to receive Medicaid prepaid capitation payments under Title 15, Subtitle 1 of the Health – General Article, shall:
(1)
pay hospitals for hospital services rendered on the basis of the rate approved by the Health Services Cost Review Commission; and
(2)
comply with the applicable terms and conditions of the all–payer model contract, as defined in § 19–201 of the Health – General Article.
Md. Code Ann., Ins. § 15-605 (2026)
Title 15. Health Insurance
Subtitle 6. Required Reimbursement of Institutions
§ 15–605LinkCopy Citation
(a)
(1)
On or before March 1 of each year, an annual report that meets the specifications of paragraph (2) of this subsection shall be submitted to the Commissioner by, as applicable in accordance with regulations adopted by the Commissioner, each managed care organization that is authorized to receive Medicaid prepaid capitation payments under Title 15, Subtitle 1 of the Health – General Article.
(2)
The annual report required under this subsection shall:
(i)
be submitted in a form required by the Commissioner; and
(ii)
include for the preceding calendar year the following data for all health benefit plans specific to the State:
(1)
premiums written;
(2)
premiums earned;
(3)
total amount of incurred claims including reserves for claims incurred but not reported at the end of the previous year;
(4)
total amount of incurred expenses, including commissions, acquisition costs, general expenses, taxes, licenses, and fees, estimated if necessary;
(5)
loss ratio; and
(6)
expense ratio.
(3)
The data required under paragraph (2) of this subsection shall be reported in the aggregate.
(4)
The Commissioner, in consultation with the Secretary of Health, shall establish and adopt by regulation a methodology to be used in the annual report that ensures a clear separation of all medical and administrative expenses whether incurred directly or through a subcontractor.
(5)
The Commissioner may conduct an examination to ensure that an annual report submitted under this subsection is accurate.
(b)
(1)
Before a managed care organization may enroll a medical assistance program recipient, the managed care organization shall provide a business plan to the Commissioner.
(2)
As part of the annual report required under subsection (a) of this section, a managed care organization shall:
(i)
provide a list of the total compensation from the managed care organization, including all cash and deferred compensation, stock, and stock options in addition to salary, of each member of the board of directors of the managed care organization, and each senior officer of the managed care organization or any subsidiary of the managed care organization as designated by the Commissioner; and
(ii)
provide any other information or documents necessary for the Commissioner to ensure compliance with this subsection and subsections (a)(3)(iii) and (c)(5), (6), and (7) of this section and for the Secretary of Health to carry out Title 15, Subtitle 1 of the Health – General Article.
(c)
(1)
(i)
Individual health insurance coverage and health insurance coverage offered in the small group and large group markets, as those terms are defined in the federal Public Health Service Act, issued or delivered in the State by an authorized insurer, nonprofit health service plan, or health maintenance organization shall comply with the loss ratio requirements of sections 1001(5) and 10101(f) of the Affordable Care Act, which amend section 2718 of the Public Health Service Act.
(ii)
The provisions of subparagraph (i) of this paragraph do not apply to coverage for excepted benefits, as defined in 45 C.F.R. § 146.145(c).
(iii)
The Commissioner may require an insurer, a nonprofit health service plan, or a health maintenance organization to file new rates if the loss ratio reported in the manner required under 45 C.F.R. § 158 is less than that required under subparagraph (i) of this paragraph.
(2)
The authority of the Commissioner under paragraph (1) of this subsection to require an insurer, nonprofit health service plan, or health maintenance organization to file new rates based on loss ratio:
(i)
is in addition to any other authority of the Commissioner under this article to require that rates not be excessive, inadequate, or unfairly discriminatory; and
(ii)
does not limit any existing authority of the Commissioner to determine whether a rate is excessive.
(3)
(i)
In determining whether to require an insurer to file new rates under this subsection, the Commissioner may consider the amount of health insurance premiums earned in the State on individual policies in proportion to the total health insurance premiums earned in the State for the insurer.
(ii)
The insurer shall provide to the Commissioner the information necessary to determine the proportion of individual health insurance premiums to total health insurance premiums as provided under this paragraph.
(4)
The Secretary of Health, in consultation with the Commissioner and in accordance with their memorandum of understanding, may adjust capitation payments for a managed care organization or for the Maryland Medical Assistance Program of a managed care organization that is a certified health maintenance organization if the loss ratio is less than 85%.
(5)
A loss ratio reported under paragraph (4) of this subsection shall be calculated separately and may not be part of another loss ratio reported under this section.
(6)
Any rebate received by a managed care organization may not be considered part of the loss ratio of the managed care organization.
(7)
If the Secretary of Health adjusts capitation payments for a managed care organization or a certified health maintenance organization under paragraph (4) of this subsection, the managed care organization or certified health maintenance organization may:
(i)
appeal the decision of the Secretary to the Board of Review established under Title 2, Subtitle 2 of the Health – General Article; and
(ii)
take any further appeal allowed by the Administrative Procedure Act under Title 10, Subtitle 2 of the State Government Article.
(8)
The Secretary of Health shall publish in a conspicuous manner on the Web site of the Maryland Department of Health:
(i)
the loss ratio, as determined by the Maryland Department of Health for each managed care organization participating in the medical assistance program, for each year during the most recent 3–year period;
(ii)
for each year during the 3–year period, the amount to be returned to the medical assistance program, if any, from a managed care organization for failing to meet the loss ratio requirement under paragraph (4) of this subsection; and
(iii)
any amount due to or received by the Maryland Department of Health from a managed care organization for each year during the 3–year period.
(d)
Each insurer, nonprofit health service plan, and health maintenance organization shall provide annually to each contract holder a written statement of the loss ratio for a health benefit plan as submitted to the Commissioner under this section.
(e)
(1)
(i)
On or before March 1 of each year, unless, for good cause shown, the Commissioner extends the time for a reasonable period, each managed care organization shall file with the Commissioner a report that shows the financial condition of the managed care organization on the last day of the preceding calendar year and any other information that the Commissioner requires by bulletin or regulation.
(ii)
At any time, the Commissioner may require a managed care organization to file an interim statement containing the information that the Commissioner considers necessary.
(iii)
The annual and interim reports shall be filed in a form required by the Commissioner.
(2)
(i)
Except as provided in paragraph (3) of this subsection on or before June 1 of each year, each managed care organization shall file with the Commissioner an audited financial report for the preceding calendar year.
(ii)
The audited financial report shall:
(1)
be filed in a form required by the Commissioner; and
(2)
be certified by an audit of an independent certified public accountant.
(3)
With 90 days’ advance notice, the Commissioner may require a managed care organization to file an audited financial report earlier than the date specified in paragraph (2) of this subsection.
(f)
Each financial report filed under this section is a public record.
Subtitle 7. Required Reimbursement for Services of Health Care Providers
Md. Code Ann., Ins. § 15-701 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–701LinkCopy Citation
(a)
(1)
This subsection applies to each individual or group health insurance policy, contract, or certificate that is:
(i)
delivered or issued for delivery in the State by an insurer or nonprofit health service plan; and
(ii)
issued, renewed, amended, or reissued on or after July 1, 1984.
(2)
Notwithstanding any other provision of a policy, contract, or certificate subject to this subsection, if the policy, contract, or certificate provides for reimbursement for a service that is within the lawful scope of practice of a health care provider licensed under the Health Occupations Article, the insured or any other person covered by or entitled to reimbursement under the policy, contract, or certificate is entitled to reimbursement for the service.
(b)
An individual or group disability insurance policy or contract that is delivered or issued for delivery in the State may not contain a provision that precludes a licensed health care provider from attesting to the rendition of service that is within the lawful scope of practice of the attesting provider.
Md. Code Ann., Ins. § 15-702 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–702LinkCopy Citation
(a)
This section applies to each self-funded group insurance plan that:
(1)
(i)
is formed by an order, society, or association that is incorporated or has a main office in the State; or
(ii)
covers individuals who reside or work in the State; and
(2)
is issued, renewed, amended, or reissued on or after July 1, 1972.
(b)
Notwithstanding any other provision of a self-funded group insurance plan subject to this section, if the plan provides for reimbursement for a service that is within the lawful scope of practice of a physician, dentist, or podiatrist, the plan may not prohibit a person covered by the plan from being reimbursed for the service regardless of whether the service is performed by a physician, dentist, or podiatrist.
Md. Code Ann., Ins. § 15-703 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–703LinkCopy Citation
(a)
In this section, “certified nurse practitioner” means a licensed registered nurse who has:
(1)
completed a nurse practitioner program approved by the State Board of Nursing; and
(2)
passed an examination approved by the State Board of Nursing.
(b)
Each insurer that proposes to issue, renew, amend, or reissue an individual, group, or blanket health insurance policy in the State that is written on an expense-incurred basis shall offer the option of providing benefits for expenses that arise from services rendered by a certified nurse practitioner.
(c)
Each nonprofit health service plan that proposes to issue, renew, amend, or reissue a health insurance policy in the State shall offer the option of providing benefits for expenses that arise from services rendered by a certified nurse practitioner.
(d)
The insurer or nonprofit health service plan may limit the coverage offered under this section for services provided by a certified nurse practitioner while working under the direct supervision of a physician.
(e)
The utilization of health insurance benefits provided under this section for services rendered by a certified nurse practitioner is subject to review by a peer review committee appointed by the State Board of Nursing.
Md. Code Ann., Ins. § 15-704 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–704LinkCopy Citation
(a)
This section applies to each individual, group, or blanket health insurance policy, contract, or certificate of an insurer or nonprofit health service plan that:
(1)
(i)
is delivered or issued for delivery in the State;
(ii)
is issued to a group that is incorporated or has a main office in the State; or
(iii)
covers individuals who reside or work in the State; and
(2)
is issued, renewed, amended, or reissued on or after October 1, 2003.
(b)
If a policy, contract, or certificate subject to this section provides for reimbursement for a service that is within the lawful scope of practice of a licensed clinical professional counselor, a licensed clinical marriage and family therapist, a licensed clinical alcohol and drug counselor, or a licensed clinical professional art therapist, the insured or any other person covered by the policy or certificate is entitled to reimbursement for the service.
Md. Code Ann., Ins. § 15-705 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–705LinkCopy Citation
For the purposes of a policy of health insurance or other insurance, a chiropractor is entitled to compensation for those services that the chiropractor is licensed to perform under the Health Occupations Article and that the chiropractor has rendered to an insured.
Md. Code Ann., Ins. § 15-706 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–706LinkCopy Citation
(a)
(1)
Subject to subsection (c) of this section, a policy, contract, or certificate described in § 15–701(a) of this subtitle may provide for reimbursement under § 15–701(a) of this subtitle for usual, customary, and reasonable charges for services rendered by a dietitian or nutritionist licensed under the Health Occupations Article if a licensed physician determines that the services are medically necessary for the treatment of cardiovascular disease, diabetes, prediabetes, obesity, malnutrition, cancer, cerebral vascular disease, or kidney disease.
(2)
Application of this subsection is limited to six visits with a dietitian or nutritionist during a 12–month period for each condition described in paragraph (1) of this subsection and to services for the treatment of obesity only if provided in conjunction with the treatment of a condition described in paragraph (1) of this subsection.
(b)
This section does not require a policy, contract, or certificate described in § 15–701(a) of this subtitle to provide coverage for services rendered by a nutritionist or dietitian.
(c)
If a service covered under a policy, contract, or certificate described in § 15–701(a) of this subtitle is provided to a hospital patient by a dietitian or nutritionist:
(1)
the usual, customary, and reasonable charges of the dietitian or nutritionist shall be included in the patient’s hospital charges; and
(2)
the dietitian or nutritionist may not bill the patient separately for the service.
Md. Code Ann., Ins. § 15-707 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–707LinkCopy Citation
(a)
This section applies to each individual, group, or blanket health insurance policy of an insurer or nonprofit health service plan that:
(1)
(i)
is delivered or issued for delivery in the State;
(ii)
is issued to a group that is incorporated or has a main office in the State; or
(iii)
covers individuals who reside or work in the State; and
(2)
is issued, renewed, amended, or reissued on or after January 1, 1978.
(b)
If a policy or certificate subject to this section provides for reimbursement for a service that is within the lawful scope of practice of a licensed certified social worker, the insured or any other person covered by the policy or certificate is entitled to reimbursement for the service regardless of whether the service is performed by a physician or licensed certified social worker–clinical.
Md. Code Ann., Ins. § 15-708 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–708LinkCopy Citation
(a)
In this section, “nurse anesthetist” means a registered nurse who is certified as a nurse anesthetist by:
(1)
the Council on Certification of Nurse Anesthetists; or
(2)
the Council on Recertification of Nurse Anesthetists.
(b)
This section applies to each individual, group, or blanket health insurance policy, contract, or certificate of an insurer or nonprofit health service plan that:
(1)
(i)
is issued or delivered in the State;
(ii)
is issued to a group that is incorporated or has a main office in the State; or
(iii)
covers individuals who reside or work in the State;
(2)
is issued, renewed, amended, or reissued on or after July 1, 1984; and
(3)
if issued by an insurer, is written on an expense-incurred basis.
(c)
Notwithstanding any other provision of a policy, contract, or certificate subject to this section, if the policy, contract, or certificate provides for reimbursement for a service that is within the lawful scope of practice of a nurse anesthetist, the insured or any other person covered by the policy, contract, or certificate is entitled to reimbursement for the service regardless of whether the service is performed by a physician or nurse anesthetist.
(d)
A policy that provides benefits under this section for services rendered by a nurse anesthetist may not require, as a condition for the payment of benefits, that the nurse anesthetist be employed by a physician.
(e)
The utilization of health insurance benefits provided under this section for services rendered by a nurse anesthetist is subject to review by a peer review committee appointed by the State Board of Nursing.
Md. Code Ann., Ins. § 15-709 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–709LinkCopy Citation
(a)
In this section, “nurse midwife” means a licensed registered nurse who is certified as a nurse midwife by the American College of Nurse-Midwives.
(b)
Each insurer that proposes to issue, renew, amend, or reissue an individual, group, or blanket health insurance policy in the State that is written on an expense-incurred basis shall offer the option of providing benefits for expenses that arise from services rendered by a nurse midwife.
(c)
Each nonprofit health service plan that proposes to issue, renew, amend, or reissue a health insurance policy in the State shall offer the option of providing benefits for expenses that arise from services rendered by a nurse midwife.
(d)
(1)
This subsection applies to each individual, group, or blanket health insurance policy, contract, or certificate of an insurer or nonprofit health service plan that:
(i)
(1)
is issued or delivered in the State;
(2)
is issued to a group that is incorporated or has a main office in the State; or
(3)
covers individuals who reside or work in the State;
(ii)
is issued, renewed, amended, or reissued on or after July 1, 1979; and
(iii)
if issued by an insurer, is written on an expense-incurred basis.
(2)
Notwithstanding any other provision of a policy, contract, or certificate subject to this subsection, if the policy, contract, or certificate provides for reimbursement for a service that is within the lawful scope of practice of a nurse midwife, the insured or any other person covered by the policy, contract, or certificate is entitled to reimbursement for the service regardless of whether the service is performed by a physician or nurse midwife.
(e)
A policy that provides benefits under this section for services rendered by a nurse midwife may not require, as a condition for the payment of benefits, that the nurse midwife be employed by a physician or act under a physician’s orders.
(f)
The utilization of health insurance benefits provided under this section for services rendered by a nurse midwife is subject to review by a peer review committee appointed by the State Board of Nursing.
Md. Code Ann., Ins. § 15-710 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–710LinkCopy Citation
(a)
This section applies to each individual or group health insurance policy or certificate of an insurer that:
(1)
is issued or delivered in the State;
(2)
is issued to a group that is incorporated or has a main office in the State; or
(3)
covers individuals who reside or work in the State.
(b)
Each policy or certificate subject to this section that provides for reimbursement for a service that is within the lawful scope of practice of an optometrist licensed under the Health Occupations Article shall require the insurer to reimburse the insured or any other person covered by the policy or certificate for the service performed by the optometrist in accordance with the other provisions of the policy or certificate.
Md. Code Ann., Ins. § 15-711 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–711LinkCopy Citation
(a)
This section applies to each individual or group health insurance policy or contract that is:
(1)
delivered or issued for delivery in the State by an insurer or nonprofit health service plan; and
(2)
issued, renewed, amended, or reissued on or after October 1, 1993.
(b)
An insurer or nonprofit health service plan may not impose a time limit on the receipt of services covered under a policy or contract subject to this section that are provided during the policy or contract period by a physical therapist licensed under the Health Occupations Article.
(c)
This section does not prohibit an insurer or nonprofit health service plan from imposing a limit on the number of visits with a licensed physical therapist that are allowed under a policy or contract.
Md. Code Ann., Ins. § 15-712 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–712LinkCopy Citation
Notwithstanding § 15-701(a) of this subtitle, unless a policy, contract, or certificate described in § 15-701(a) of this subtitle expressly provides for reimbursement for a service that is within the lawful scope of practice of a physician assistant certified under the Health Occupations Article, the provisions of the Health Occupations Article that govern the certification and regulation of physician assistants may not be construed to entitle the insured or any other person covered by the policy, contract, or certificate to reimbursement for the service.
Md. Code Ann., Ins. § 15-713 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–713LinkCopy Citation
(a)
This section applies to individual, group, or blanket health insurance policies and contracts delivered or issued for delivery in the State by insurers, nonprofit health service plans, and health maintenance organizations.
(b)
Notwithstanding any other provision of an individual, group, or blanket health insurance policy or contract subject to this section, if the policy or contract provides for reimbursement for a service that is within the lawful scope of practice of a licensed podiatrist, the insured or any other person covered by or entitled to reimbursement under the policy or contract is entitled to the same amount of reimbursement for the service regardless of whether the service is performed by a physician or licensed podiatrist.
(c)
This section does not prohibit, and may not be construed as prohibiting, the determination of reimbursement based on the geographic location of the delivery of service, the preeminent qualifications of a physician or podiatrist, or the need to provide services in an underserved area of the State.
Md. Code Ann., Ins. § 15-714 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–714LinkCopy Citation
(a)
This section applies to each individual or group health insurance policy, contract, or certificate that:
(1)
(i)
is issued or delivered in the State;
(ii)
is issued to a group that is incorporated or has a main office in the State; or
(iii)
covers individuals who reside or work in the State; and
(2)
is issued, renewed, amended, or reissued on or after July 1, 1972.
(b)
Notwithstanding any other provision of a policy, contract, or certificate subject to this section, if the policy, contract, or certificate provides for reimbursement for a service that is within the lawful scope of practice of a licensed psychologist, the insured or any other person covered by the policy, contract, or certificate is entitled to reimbursement for the service regardless of whether the service is performed by a physician or licensed psychologist.
Md. Code Ann., Ins. § 15-715 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–715LinkCopy Citation
(a)
This section applies to each individual or group health insurance policy or contract that is issued or delivered in the State by an insurer, nonprofit health service plan, or health maintenance organization.
(b)
To the extent required under federal law, an insurer, nonprofit health service plan, or health maintenance organization shall reimburse a community health resource, as defined in § 19-2101 of the Health - General Article, for covered services provided to the insured or any other person covered by the policy or contract.
Md. Code Ann., Ins. § 15-716 (2026)
Title 15. Health Insurance
Subtitle 7. Required Reimbursement for Services of Health Care Providers
§ 15–716LinkCopy Citation
(a)
This section applies to individual, group, or blanket health insurance policies and contracts delivered or issued for delivery in the State by insurers, nonprofit health service plans, and health maintenance organizations that provide coverage for services that are within the lawful scope of practice of a licensed pharmacist.
(b)
An entity subject to this section shall provide coverage for services rendered by a licensed pharmacist acting within the pharmacist’s lawful scope of practice to an individual who is covered under a policy or contract issued or delivered by the entity, to the same extent as services rendered by any other licensed health care practitioner.
(c)
Reimbursement for services provided under this section may not be conditioned on whether the licensed pharmacist is:
(1)
employed by a physician, pharmacy, or facility; or
(2)
acting under a physician’s orders.
Subtitle 8. Required Health Insurance Benefits
Md. Code Ann., Ins. § 15-801 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–801LinkCopy Citation
(a)
This section applies to:
(1)
insurers that propose to issue or deliver in the State group or blanket health insurance policies that are written on an expense-incurred basis; and
(2)
nonprofit health service plans that propose to issue or deliver in the State group medical or major medical contracts that are written on an expense-incurred basis.
(b)
An entity subject to this section shall offer the policyholder the option of providing benefits for expenses arising from the care, including nursing home care and intermediate or custodial nursing care, of individuals who have Alzheimer’s disease.
(c)
An entity subject to this section shall offer the policyholder the option of providing benefits for expenses arising from the care of elderly individuals, including nursing home care and intermediate or custodial nursing care of elderly individuals who have any disease, other than Alzheimer’s disease, that is designated in regulations adopted by the Commissioner.
(d)
An entity subject to this section may establish reasonable limits on the benefits offered under this section, including copayment and deductible provisions and maximum annual and lifetime dollar limits.
Md. Code Ann., Ins. § 15-802 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–802LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Alcohol misuse” has the meaning stated in § 8–101 of the Health – General Article.
(3)
“ASAM criteria” means the most recent edition of the American Society of Addiction Medicine treatment criteria for addictive, substance–related, and co–occurring conditions that establishes guidelines for placement, continued stay and transfer or discharge of patients with addiction and co–occurring conditions.
(4)
“Drug misuse” has the meaning stated in § 8–101 of the Health – General Article.
(5)
“Grandfathered health plan coverage” has the meaning stated in 45 C.F.R. § 147.140.
(6)
“Health benefit plan” means:
(i)
for a group or blanket plan, a health benefit plan as defined in § 15–1401 of this title;
(ii)
for an individual plan, a health benefit plan as defined in § 15–1301(l) of this title; or
(iii)
short–term limited duration insurance as defined in § 15–1301(s) of this title.
(7)
“Managed care system” means a system of cost containment methods that a carrier uses to review and preauthorize a treatment plan developed by a health care provider for a covered individual in order to control utilization, quality, and claims.
(8)
“Partial hospitalization” means the provision of medically directed intensive or intermediate short–term treatment:
(i)
to an insured, subscriber, or member;
(ii)
in a licensed or certified facility or program;
(iii)
for mental illness, emotional disorders, drug misuse, or alcohol misuse; and
(iv)
for a period of less than 24 hours but more than 4 hours in a day.
(9)
“Small employer” has the meaning stated in § 31–101 of this article.
(b)
With the exception of small employer grandfathered health plan coverage, this section applies to each individual, group, and blanket health benefit plan that is delivered or issued for delivery in the State by an insurer, a nonprofit health service plan, or a health maintenance organization.
(c)
A health benefit plan subject to this section shall provide at least the following benefits for the diagnosis and treatment of a mental illness, emotional disorder, drug use disorder, or alcohol use disorder:
(1)
inpatient benefits for services provided in a licensed or certified facility, including hospital inpatient and residential treatment center benefits;
(2)
partial hospitalization benefits; and
(3)
outpatient and intensive outpatient benefits, including all office visits, diagnostic evaluation, opioid treatment services, medication evaluation and management, and psychological and neuropsychological testing for diagnostic purposes.
(d)
(1)
The benefits under this section are required only for expenses arising from the treatment of mental illnesses, emotional disorders, drug misuse, or alcohol misuse if, in the professional judgment of health care providers:
(i)
the mental illness, emotional disorder, drug misuse, or alcohol misuse is treatable; and
(ii)
the treatment is medically necessary.
(2)
The benefits required under this section:
(i)
shall be provided as one set of benefits covering mental illnesses, emotional disorders, drug misuse, and alcohol misuse;
(ii)
shall comply with 45 C.F.R. § 146.136(a) through (d) and 29 C.F.R. § 2590.712(a) through (d);
(iii)
subject to paragraph (3) of this subsection, may be delivered under a managed care system; and
(iv)
for partial hospitalization under subsection (c)(2) of this section, may not be less than 60 days.
(3)
The benefits required under this section may be delivered under a managed care system only if the benefits for physical illnesses covered under the health benefit plan are delivered under a managed care system.
(4)
The processes, strategies, evidentiary standards, or other factors used to manage the benefits required under this section must be comparable as written and in operation to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used to manage the benefits for physical illnesses covered under the health benefit plan.
(5)
An insurer, nonprofit health service plan, or health maintenance organization shall use the ASAM criteria for all medical necessity and utilization management determinations for substance use disorder benefits.
(e)
An entity that issues or delivers a health benefit plan subject to this section shall provide on its website and annually in print to its insureds or members:
(1)
notice about the benefits required under this section and the federal Mental Health Parity and Addiction Equity Act; and
(2)
notice that the insured or member may contact the Administration for further information about the benefits.
(f)
An entity that issues or delivers a health benefit plan subject to this section shall:
(1)
post a release of information authorization form on its website; and
(2)
provide a release of information authorization form by standard mail within 10 business days after a request for the form is received.
Md. Code Ann., Ins. § 15-803 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–803LinkCopy Citation
(a)
An insurer or nonprofit health service plan that issues or delivers an individual, group, or blanket health insurance policy or contract in the State, or a health maintenance organization that issues or delivers an individual or group contract in the State, may not exclude payments for blood products, both derivatives and components, that otherwise would be covered under the health insurance contract.
(b)
This section does not apply to whole blood or concentrated red blood cells.
Md. Code Ann., Ins. § 15-804 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–804LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Medical literature” means scientific studies published in a peer–reviewed national professional medical journal.
(3)
“Off–label use” means the prescription of a drug for a treatment other than those treatments stated in the labeling approved by the federal Food and Drug Administration.
(4)
“Standard reference compendia” means any authoritative compendia as recognized periodically by the federal Secretary of Health and Human Services or the Commissioner.
(b)
This section does not:
(1)
alter any law that limits the coverage of drugs that have not been approved by the federal Food and Drug Administration;
(2)
require coverage of a drug if the federal Food and Drug Administration has determined use of the drug to be contraindicated; or
(3)
require coverage of experimental drugs not approved for any indication by the federal Food and Drug Administration.
(c)
(1)
This subsection applies to each health insurance policy or contract that is delivered or issued for delivery in the State to an employer or individual on a group or individual basis, including a contract issued by a health maintenance organization.
(2)
A policy or contract subject to this subsection that provides coverage for drugs may not exclude coverage of a drug for an off–label use of the drug if the drug is recognized for treatment in any of the standard reference compendia or in the medical literature.
(3)
Coverage of a drug required by this subsection also includes medically necessary services associated with the administration of the drug.
(d)
The Commissioner may direct a person, including a health maintenance organization, that issues a health insurance policy or contract to make payments required by this section.
Md. Code Ann., Ins. § 15-805 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–805LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Authorized prescriber” means a licensed dentist, licensed physician, or licensed podiatrist who is authorized under the Health Occupations Article to prescribe a pharmaceutical product.
(3)
“Pharmaceutical product” means a drug or medicine that may be prescribed by an authorized prescriber.
(b)
This section does not apply to a policy or contract that is issued to an employer under a collective bargaining agreement.
(c)
(1)
This subsection applies to each policy or contract that is issued or delivered in the State to an employer or individual by an insurer or nonprofit health service plan and that provides group or individual hospital, medical, or surgical benefits.
(2)
A policy or contract subject to this subsection that provides reimbursement for a pharmaceutical product prescribed by an authorized prescriber may not establish the amount of reimbursement to the insured or the insured’s beneficiary, including copayments and deductibles, based on the identity, practicing specialty, or occupation of the authorized prescriber.
(d)
(1)
This subsection applies to each individual or group policy or contract that is issued or delivered in the State to an employer or individual by an insurer or nonprofit health service plan and that provides benefits for pharmaceutical products.
(2)
A policy or contract subject to this subsection may not impose a copayment, deductible, or other condition on an insured or certificate holder who uses the services of a community pharmacy that is not imposed when the insured or certificate holder uses the services of a mail order pharmacy, if the benefits are provided under the same program, policy, or contract.
Md. Code Ann., Ins. § 15-806 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–806LinkCopy Citation
A nonprofit health service plan that provides pharmaceutical services shall allow a subscriber, member, or beneficiary to fill prescriptions at the pharmacy of the subscriber’s, member’s, or beneficiary’s choice.
Md. Code Ann., Ins. § 15-807 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–807LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Inherited metabolic disease” means a disease caused by an inherited abnormality of body chemistry.
(ii)
“Inherited metabolic disease” includes a disease for which the State screens newborn babies.
(3)
(i)
“Low protein modified food product” means a food product that is:
(1)
specially formulated to have less than 1 gram of protein per serving; and
(2)
intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease.
(ii)
“Low protein modified food product” does not include a natural food that is naturally low in protein.
(4)
“Medical food” means a food that is:
(i)
intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation; and
(ii)
formulated to be consumed or administered enterally under the direction of a physician.
(b)
This section applies to each individual hospital or major medical insurance policy, group or blanket health insurance policy, and nonprofit health service plan that:
(1)
is delivered or issued for delivery in the State;
(2)
is written on an expense-incurred basis; and
(3)
provides coverage for a family member of the insured.
(c)
A policy or plan subject to this section shall include under the family member coverage, coverage for medical foods and low protein modified food products for the treatment of inherited metabolic diseases if the medical foods or low protein modified food products are:
(1)
prescribed as medically necessary for the therapeutic treatment of inherited metabolic diseases; and
(2)
administered under the direction of a physician.
Md. Code Ann., Ins. § 15-808 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–808LinkCopy Citation
(a)
In this section, “home health care” means the continued care and treatment of a covered individual if:
(1)
institutionalization of the individual would have been required if home health care was not provided; and
(2)
the individual’s physician establishes and approves in writing the plan of treatment covering the home health care service.
(b)
This section applies to each individual, group, or blanket health insurance policy that is issued or delivered in the State by an insurer or nonprofit health service plan.
(c)
A policy subject to this section that provides coverage for inpatient hospital care on an expense-incurred basis shall provide benefits for the expenses of home health care that is provided by a person licensed under the Health Occupations Article.
(d)
Home health care shall be provided by:
(1)
a hospital that has a valid operating certificate and is certified to provide home health care services; or
(2)
a public or private health service or agency that is licensed as a home health agency under Title 19, Subtitle 4 of the Health - General Article to provide coordinated home health care.
(e)
(1)
A contract may limit the number of home health care visits, but not to fewer than 40 visits in a calendar year or in a continuous 12-month period for each individual covered under the contract.
(2)
In determining the benefits for home health care available to a covered individual:
(i)
each visit by a member of a home health care team is considered one home health care visit; and
(ii)
up to 4 hours of home health care service is considered one home health care visit.
Md. Code Ann., Ins. § 15-809 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–809LinkCopy Citation
(a)
(1)
Each insurer that issues or delivers individual health insurance policies in the State that are written on an expense-incurred basis shall offer benefits for hospice care services to its insureds.
(2)
Each insurer that issues or delivers group or blanket health insurance policies or contracts in the State that are written on an expense-incurred basis shall offer benefits for hospice care services to its policyholders or beneficiaries.
(b)
Each nonprofit health service plan shall offer benefits for hospice care services to its subscribers.
Md. Code Ann., Ins. § 15-810 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–810LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section that provides coverage for infertility benefits other than in vitro fertilization may not require as a condition of that coverage, for a patient who is married to an individual of the same sex:
(1)
that the patient’s spouse’s sperm be used in the covered treatments or procedures; or
(2)
that the patient demonstrate infertility exclusively by means of a history of unsuccessful heterosexual intercourse.
(c)
(1)
This subsection does not apply to insurers, nonprofit health service plans, and health maintenance organizations that provide hospital, medical, or surgical benefits under health insurance policies or contracts:
(i)
that are issued or delivered to a small employer in the State; and
(ii)
for which the Administration has determined that in vitro fertilization procedures are not essential health benefits, as determined under § 31–116 of this article.
(2)
An entity subject to this section that provides pregnancy–related benefits may not exclude benefits for all outpatient expenses arising from in vitro fertilization procedures performed on a policyholder or subscriber or on the dependent spouse of a policyholder or subscriber.
(3)
The benefits under this subsection shall be provided:
(i)
for insurers and nonprofit health service plans, to the same extent as the benefits provided for other pregnancy–related procedures; and
(ii)
for health maintenance organizations, to the same extent as the benefits provided for other infertility services.
(d)
Subsection (c) of this section applies if:
(1)
the patient is the policyholder or subscriber or a covered dependent of the policyholder or subscriber;
(2)
for a married patient whose spouse is of the opposite sex, the patient’s oocytes are fertilized with the patient’s spouse’s sperm, unless:
(i)
the patient’s spouse is unable to produce and deliver functional sperm; and
(ii)
the inability to produce and deliver functional sperm does not result from:
(1)
a vasectomy; or
(2)
another method of voluntary sterilization;
(3)
(i)
for a married patient, the patient and the patient’s spouse have a history of involuntary infertility, which may be demonstrated by a history of:
(1)
if the patient and the patient’s spouse are of opposite sexes, intercourse of at least 1 year’s duration failing to result in pregnancy; or
(2)
if the patient and the patient’s spouse are of the same sex, three attempts of artificial insemination over the course of 1 year failing to result in pregnancy; or
(ii)
the infertility of the patient or the patient’s spouse is associated with any of the following medical conditions:
(1)
endometriosis;
(2)
exposure in utero to diethylstilbestrol, commonly known as DES;
(3)
blockage of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy); or
(4)
abnormal male factors, including oligospermia, contributing to the infertility;
(4)
for an unmarried patient:
(i)
the patient has had three attempts of artificial insemination over the course of 1 year failing to result in pregnancy; or
(ii)
the infertility is associated with any of the following medical conditions of the patient:
(1)
endometriosis;
(2)
exposure in utero to diethylstilbestrol, commonly known as DES;
(3)
blockage of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy); or
(4)
abnormal male factors, including oligospermia, contributing to the infertility;
(5)
the patient has been unable to attain a successful pregnancy through a less costly infertility treatment for which coverage is available under the policy or contract; and
(6)
the in vitro fertilization procedures are performed at medical facilities that conform to applicable guidelines or minimum standards issued by the American College of Obstetricians and Gynecologists or the American Society for Reproductive Medicine.
(e)
An entity subject to this section may limit coverage of the benefits for in vitro fertilization required under this section to three in vitro fertilization attempts per live birth, not to exceed a maximum lifetime benefit of $100,000.
(f)
An entity subject to this section is not responsible for any costs incurred by a policyholder or subscriber or a dependent of a policyholder or subscriber in obtaining donor sperm.
(g)
A denial of coverage for in vitro fertilization benefits required under this section by an entity subject to this section constitutes an adverse decision under Subtitle 10A of this title.
(h)
This section may not be construed to require an entity subject to this section to provide coverage for a treatment or a procedure that would not treat a diagnosed medical condition of a patient.
(i)
Notwithstanding any other provision of this section, if the coverage required under this section conflicts with the bona fide religious beliefs and practices of a religious organization, on request of the religious organization, an entity subject to this section shall exclude the coverage otherwise required under this section in a policy or contract with the religious organization.
Md. Code Ann., Ins. § 15-810.1 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–810.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Iatrogenic infertility” means an impairment of fertility caused directly or indirectly by surgery, chemotherapy, radiation, or other medical treatment affecting the reproductive organs or processes.
(3)
“Medical treatment that may directly or indirectly cause iatrogenic infertility” means medical treatment with a likely side effect of infertility as established by the American Society for Reproductive Medicine, the American College of Obstetricians and Gynecologists, or the American Society of Clinical Oncology.
(4)
(i)
“Standard fertility preservation procedures” means procedures to preserve fertility that are consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American College of Obstetricians and Gynecologists, or the American Society of Clinical Oncology.
(ii)
“Standard fertility preservation procedures” includes sperm and oocyte cryopreservation and evaluations, laboratory assessments, medications, and treatments associated with sperm and oocyte cryopreservation.
(iii)
“Standard fertility preservation procedures” does not include the storage of sperm or oocytes.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
Except as provided in subsection (d) of this section, an entity subject to this section shall provide coverage for standard fertility preservation procedures:
(1)
performed on a policyholder or subscriber or on the covered dependent of a policyholder or subscriber; and
(2)
that are medically necessary to preserve fertility for a policyholder or subscriber or for the covered dependent of a policyholder or subscriber due to a need for medical treatment that may directly or indirectly cause iatrogenic infertility.
(d)
An entity subject to this section may not be required to provide coverage under subsection (c) of this section to a religious organization that requests and receives an exclusion from in vitro fertilization coverage under § 15–810(i) of this subtitle.
Md. Code Ann., Ins. § 15-811 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–811LinkCopy Citation
(a)
Each insurer and nonprofit health service plan that issues or delivers an individual, group, or blanket health insurance policy in the State that provides hospitalization benefits for normal pregnancy shall provide hospitalization benefits for childbirth to the same extent as the hospitalization benefits provided in the policy for any covered illness.
(b)
(1)
In addition to the provisions of subsection (a) of this section and § 15-812 of this subtitle, whenever a mother is required to remain hospitalized after childbirth for medical reasons and the mother requests that the newborn remain in the hospital, the insurer or nonprofit health service plan shall pay the cost of additional hospitalization for the newborn for up to 4 days.
(2)
The attending physician or certified nurse midwife of the mother, or designee of the attending physician or certified nurse midwife, shall provide notice to the mother of the provisions of paragraph (1) of this subsection.
Md. Code Ann., Ins. § 15-812 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–812LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Attending provider” means an obstetrician, pediatrician, other physician, certified nurse midwife, or pediatric nurse practitioner attending a mother or newborn child.
(3)
“High-deductible health plan” means a health benefit plan that meets the federal requirements established by § 1201 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide inpatient hospitalization coverage to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide inpatient hospitalization coverage to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section shall provide coverage for the cost of inpatient hospitalization services for a mother and newborn child for a minimum of:
(1)
48 hours of inpatient hospitalization care after an uncomplicated vaginal delivery; and
(2)
96 hours of inpatient hospitalization care after an uncomplicated cesarean section.
(d)
A mother may request a shorter length of stay than that provided in subsection (c) of this section if the mother decides, in consultation with the mother’s attending provider, that less time is needed for recovery.
(e)
(1)
For a mother and newborn child who have a shorter hospital stay than that provided under subsection (c) of this section, an entity subject to this section shall provide coverage for:
(i)
one home visit scheduled to occur within 24 hours after hospital discharge; and
(ii)
an additional home visit if prescribed by the attending provider.
(2)
For a mother and newborn child who remain in the hospital for at least the length of time provided under subsection (c) of this section, an entity subject to this section shall provide coverage for a home visit if prescribed by the attending provider.
(3)
A home visit under paragraph (1) or (2) of this subsection shall:
(i)
be provided in accordance with generally accepted standards of nursing practice for home care of a mother and newborn child;
(ii)
be provided by a registered nurse with at least 1 year of experience in maternal and child health nursing or community health nursing with an emphasis on maternal and child health; and
(iii)
include any services required by the attending provider.
(f)
An entity subject to this section may not deny, limit, or otherwise impair the participation of an attending provider under contract with the entity in providing health care services to enrollees or insureds for:
(1)
advocating the interest of a mother and newborn child through the entity’s utilization review or appeals system;
(2)
advocating more than 48 hours of inpatient hospital care after a complicated vaginal delivery or more than 96 hours of inpatient hospital care after a complicated cesarean section; or
(3)
prescribing a home visit under subsection (e)(1)(ii) or (2) of this section.
(g)
(1)
Except as provided in paragraph (2) of this subsection, an entity subject to this section may not impose a copayment or coinsurance requirement or deductible for coverage required under subsection (e)(1) or (2) of this section or refuse reimbursement under subsection (e)(1) of this section if the services do not occur within the time specified.
(2)
If an insured or enrollee is covered under a high-deductible health plan, an entity subject to this section may require that the coverage required under subsection (e)(1) and (2) of this section be subject to the deductible of the high-deductible health plan.
(h)
An entity subject to this section shall provide notice annually to insureds and enrollees about the coverage provided by this section.
Md. Code Ann., Ins. § 15-813 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–813LinkCopy Citation
(a)
This section applies to each group or blanket health insurance policy that:
(1)
is issued or delivered in the State;
(2)
is issued or delivered to an entity that is incorporated or has a main office in the State; or
(3)
covers individuals who reside or work in the State.
(b)
Each insurer that proposes to issue a policy subject to this section that provides benefits for temporary disability shall offer the policyholder the option of providing benefits for temporary disability caused or contributed to by pregnancy or childbirth.
(c)
The benefits under this section shall be provided to the same extent and on the same terms as the benefits provided for any other covered disability.
Md. Code Ann., Ins. § 15-814 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–814LinkCopy Citation
(a)
In this section, “digital tomosynthesis” means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross–sectional digital three–dimensional images of the breast.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
(1)
Subject to paragraph (2) of this subsection, an entity subject to this section shall provide coverage for breast cancer screening in accordance with the latest screening guidelines issued by the American Cancer Society.
(2)
The coverage required under this section shall include coverage for digital tomosynthesis that, under accepted standards in the practice of medicine, the treating physician determines is medically appropriate and necessary for an enrollee or insured.
(d)
An entity subject to this section is not required to cover breast cancer screenings used to identify breast cancer in asymptomatic women that are provided by a facility that is not accredited by the American College of Radiology or certified or licensed under a program established by the State.
(e)
(1)
An entity subject to this section may not impose a deductible on the coverage required under this section.
(2)
Each health insurance policy and certificate issued by an entity subject to this section shall contain a notice of the prohibition established by paragraph (1) of this subsection in a form approved by the Commissioner.
(3)
An entity subject to this section may not impose a copayment or coinsurance requirement for digital tomosynthesis that is greater than a copayment or coinsurance requirement for other breast cancer screenings for which coverage is required under this section.
Md. Code Ann., Ins. § 15-814.1 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–814.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Diagnostic breast examination” means a medically necessary and appropriate examination of the breast that is used to evaluate an abnormality that is:
(1)
seen or suspected from a prior screening examination for breast cancer; or
(2)
detected by another means of prior examination.
(ii)
“Diagnostic breast examination” includes an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound.
(3)
(i)
“Supplemental breast examination” means a medically necessary examination of the breast that is used to screen for breast cancer when:
(1)
there is no abnormality seen or suspected from a prior examination; and
(2)
there is a personal or family medical history or additional factors that may increase an individual’s risk of breast cancer.
(ii)
“Supplemental breast examination” includes an examination using breast magnetic resonance imaging, breast ultrasound, or image–guided breast biopsy.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide coverage for diagnostic breast examinations or supplemental breast examinations under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide coverage for diagnostic breast examinations or supplemental breast examinations under individual or group contracts that are issued or delivered in the State.
(c)
(1)
Except as provided in paragraph (2) of this subsection, an entity subject to this section may not impose a copayment, coinsurance, or deductible requirement on coverage for diagnostic breast examinations or supplemental breast examinations.
(2)
If an insured or enrollee is covered under a high–deductible health plan, as defined in 26 U.S.C. § 223, an entity subject to this section may subject diagnostic breast examinations or supplemental breast examinations to the deductible requirement of the high–deductible health plan.
Md. Code Ann., Ins. § 15-815 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–815LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Mastectomy” means the surgical removal of all or part of a breast.
(3)
(i)
“Reconstructive breast surgery” means surgery performed as a result of a mastectomy to reestablish symmetry between the two breasts.
(ii)
“Reconstructive breast surgery” includes augmentation mammoplasty, reduction mammoplasty, and mastopexy.
(b)
This section applies to contracts issued by:
(1)
insurers and nonprofit health service plans that provide medical and surgical benefits to individuals or groups on an expense–incurred basis under health insurance contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide medical and surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
A contract subject to this section shall provide coverage for:
(1)
reconstructive breast surgery, including coverage for all stages of reconstructive breast surgery performed on a nondiseased breast to establish symmetry with the diseased breast when reconstructive breast surgery is performed on the diseased breast; and
(2)
physical complications of all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending physician and the patient.
Md. Code Ann., Ins. § 15-816 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–816LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section:
(1)
shall classify an obstetrician/gynecologist as a primary care provider; or
(2)
if the obstetrician/gynecologist chooses not to be a primary care provider, shall allow a woman to receive routine gynecological care from an in-network obstetrician/gynecologist without requiring the woman to visit a primary care provider first, if:
(i)
the care is medically necessary, including care that is routine;
(ii)
after each visit for gynecological care, the obstetrician/gynecologist communicates with the woman’s primary care provider about any diagnosis or treatment rendered; and
(iii)
the obstetrician/gynecologist confers with the primary care provider before performing any diagnostic procedure that is not routine gynecological care rendered during an annual visit.
(c)
If an entity subject to this section classifies an obstetrician/gynecologist as a primary care provider as provided in subsection (b) of this section, and a woman does not choose an obstetrician/gynecologist as the woman’s primary care provider, the entity shall allow the woman an annual visit to an in-network obstetrician/gynecologist for routine gynecological care without requiring the woman to visit the woman’s primary care provider first, whether or not the primary care provider is qualified to and regularly does provide routine gynecological care.
(d)
(1)
An entity subject to this section shall allow a woman to receive medically necessary, routine obstetric and gynecological care from an in-network, certified nurse midwife or any other in-network provider authorized under the Health Occupations Article to provide obstetric and gynecological services without first requiring the woman to visit a primary care provider.
(2)
A certified nurse midwife or other nonphysician provider authorized under the Health Occupations Article to provide obstetric and gynecological services shall consult with an obstetrician/gynecologist with whom the certified nurse midwife or other provider has a collaborative agreement, in accordance with the collaborative agreement, regarding any care rendered under this subsection.
Md. Code Ann., Ins. § 15-817 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–817LinkCopy Citation
(a)
In this section, “child wellness services” means preventive activities designed to protect children from morbidity and mortality and promote child development.
(b)
This section applies to each individual hospital or major medical insurance policy, group or blanket health insurance policy, and nonprofit health service plan that:
(1)
is delivered or issued for delivery in the State;
(2)
is written on an expense–incurred basis; and
(3)
provides coverage for a family member of the insured.
(c)
(1)
A policy or plan subject to this section shall include under the family member coverage a minimum package of child wellness services that are consistent with:
(i)
public health policy;
(ii)
professional standards; and
(iii)
scientific evidence of effectiveness.
(2)
The minimum package of child wellness services shall cover at least:
(i)
all visits for and costs of childhood and adolescent immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention as of December 31, 2024, as updated by recommendations issued by the Secretary of Health in accordance with § 18–112 of the Health – General Article;
(ii)
visits for the collection of adequate samples, the first of which is to be collected before 2 weeks of age, for hereditary and metabolic newborn screening and follow–up between birth and 4 weeks of age;
(iii)
universal hearing screening of newborns provided by a hospital before discharge;
(iv)
all visits for and costs of age–appropriate screening tests for tuberculosis, anemia, lead toxicity, hearing, and vision as determined by the American Academy of Pediatrics;
(v)
all visits for obesity evaluation and management;
(vi)
all visits for and costs of developmental screening as recommended by the American Academy of Pediatrics;
(vii)
a physical examination, developmental assessment, and parental anticipatory guidance services at each of the visits required under items (i), (ii), (iv), (v), and (vi) of this paragraph; and
(viii)
any laboratory tests considered necessary by the physician as indicated by the services provided under items (i), (ii), (iv), (v), (vi), or (vii) of this paragraph.
(d)
Except as provided in subsection (e) of this section, an insurer or nonprofit health service plan that issues a policy or plan subject to this section, on notification of the pregnancy of the insured and before the delivery date, shall:
(1)
encourage and help the insured to choose and contact a primary care provider for the expected newborn before delivery; and
(2)
provide the insured with information on postpartum home visits for the mother and the expected newborn, including the names of health care providers that are available for postpartum home visits.
(e)
An insurer or nonprofit health service plan that does not require or encourage the insured to use a particular health care provider or group of health care providers that has contracted with the insurer or nonprofit health service plan to provide services to the insurer’s or nonprofit health service plan’s insureds need not comply with subsection (d) of this section.
(f)
(1)
A policy or plan subject to this section may not impose a deductible on the coverage required under this section.
(2)
Each health insurance policy and certificate shall contain a notice of the prohibition established by paragraph (1) of this subsection in a form approved by the Commissioner.
(g)
The Commissioner may adopt regulations necessary to carry out subsection (c)(2)(i) of this section consistent with federal statutes, rules, and guidance in effect on December 31, 2024, as updated by recommendations issued by the Secretary of Health in accordance with § 18–112 of the Health – General Article.
Md. Code Ann., Ins. § 15-818 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–818LinkCopy Citation
(a)
This section applies to:
(1)
each individual or group hospital or major medical insurance policy or certificate that is delivered or issued for delivery in the State by an insurer and is written on an expense–incurred basis;
(2)
each individual or group medical or major medical contract, policy, or certificate that is delivered or issued for delivery in the State by a nonprofit health service plan; and
(3)
each contract that provides hospital, medical, or surgical benefits to individuals or groups and is issued or delivered in the State by a health maintenance organization.
(b)
A policy, contract, or certificate subject to this section shall include benefits for inpatient or outpatient expenses arising from orthodontics, oral surgery, and otologic, audiological, and speech/language treatment involved in the management of the birth defect known as cleft lip or cleft palate or both.
Md. Code Ann., Ins. § 15-819 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–819LinkCopy Citation
(a)
This section applies to:
(1)
each individual, group, or blanket health insurance policy that is issued or delivered in the State by an insurer; and
(2)
each contract or certificate that is issued or delivered in the State by a nonprofit health service plan.
(b)
A policy, contract, or certificate subject to this section that provides coverage for an inpatient service in an acute general hospital shall provide coverage for:
(1)
a corresponding outpatient service that is provided to the insured instead of the inpatient service because of the denial, after review under a utilization review program, of a request by the attending physician for an inpatient admission; and
(2)
an objective second opinion given to the insured when required by a utilization review program under § 19-319 of the Health - General Article.
Md. Code Ann., Ins. § 15-820 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–820LinkCopy Citation
(a)
In this section, “orthopedic brace” means a rigid or semi–rigid device that is used to:
(1)
support a weak or deformed body member; or
(2)
restrict or eliminate motion in a diseased or injured part of the body.
(b)
Each health insurance contract that is delivered or issued for delivery in the State by a nonprofit health service plan and that provides hospital benefits shall provide benefits for orthopedic braces.
Md. Code Ann., Ins. § 15-821 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–821LinkCopy Citation
(a)
This section applies to each policy or contract that is issued or delivered in the State to an employer or individual by an insurer or nonprofit health service plan.
(b)
(1)
A policy or contract subject to this section that provides coverage on a group or individual basis for a diagnostic or surgical procedure involving a bone or joint of the skeletal structure may not exclude or deny coverage for the same diagnostic or surgical procedure involving a bone or joint of the face, neck, or head if, under the accepted standards of the profession of the health care provider rendering the service, the procedure is medically necessary to treat a condition caused by a congenital deformity, disease, or injury.
(2)
This subsection does not apply to intraoral prosthetic devices.
(c)
(1)
This section does not affect any other coverage required under this article or restrict the scope of coverage under a policy or contract subject to this section.
(2)
This section is not intended to encourage surgical procedures over appropriate nonsurgical procedures, or to prohibit the continued coverage of nonsurgical procedures in the treatment of a bone or joint of the face, neck, or head.
Md. Code Ann., Ins. § 15-822 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–822LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section shall provide coverage for all medically appropriate and necessary diabetes equipment, diabetes supplies, and diabetes outpatient self–management training and educational services, including medical nutrition therapy, that the insured’s or enrollee’s treating physician or other appropriately licensed health care provider, or a physician who specializes in the treatment of diabetes, certifies are necessary for the treatment of:
(1)
insulin–using diabetes;
(2)
noninsulin–using diabetes;
(3)
elevated or impaired blood glucose levels induced by pregnancy; or
(4)
consistent with the American Diabetes Association’s standards, elevated or impaired blood glucose levels induced by prediabetes.
(c)
If certified as necessary under subsection (b) of this section, the diabetes outpatient self–management training and educational services, including medical nutrition therapy, to be provided to the insured or enrollee shall be provided through a program supervised by an appropriately licensed, registered, or certified health care provider whose scope of practice includes diabetes education or management.
(d)
(1)
Subject to paragraph (2) of this subsection, and except as provided in paragraph (3) of this subsection, the coverage required under this section may be subject to the annual deductibles or coinsurance requirements imposed by an entity subject to this section for similar coverages under the same health insurance policy or contract.
(2)
Except as provided in paragraph (3) of this subsection, the annual deductibles or coinsurance requirements imposed under paragraph (1) of this subsection for the coverage required under this section may not be greater than the annual deductibles or coinsurance requirements imposed by the entity for similar coverages.
(3)
(i)
Except as provided in subparagraph (ii) of this paragraph, an entity subject to this section may not impose a deductible, copayment, or coinsurance requirement on diabetes test strips.
(ii)
If an insured or enrollee is covered under a high–deductible health plan, as defined in 26 U.S.C. § 223, an entity subject to this section may subject diabetes test strips to the deductible requirement of the high–deductible health plan.
(e)
An entity subject to this section may not reduce or eliminate coverages in its health insurance policies or contracts due to the requirements of this section.
Md. Code Ann., Ins. § 15-822.1 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–822.1LinkCopy Citation
(a)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs and devices to individuals or groups under health insurance policies or contracts that are delivered in the State; and
(ii)
health maintenance organizations that provide coverage for prescription drugs and devices to individuals or groups under contracts that are issued or delivered in the State.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for prescription drugs and devices through a pharmacy benefits manager is subject to the requirements of this section.
(b)
An entity subject to this section shall limit the amount a covered individual is required to pay in copayments or coinsurance for a covered prescription insulin drug to not more than $30 for a 30–day supply, regardless of the amount or type of insulin needed to fill the covered individual’s prescription.
(c)
An entity subject to this section may set the amount a covered individual is required to pay to an amount that is less than the payment amount limit under subsection (b) of this section.
(d)
A contract between an entity subject to this section, or a pharmacy benefits manager through which the entity provides coverage for prescription drugs and devices, and a pharmacy or the pharmacy’s contracting agent, may not:
(1)
authorize a party to the contract to charge a covered individual an amount that is more than the payment amount limit under subsection (b) of this section;
(2)
require a pharmacy to collect from a covered individual an amount that is more than the payment amount limit under subsection (b) of this section; or
(3)
require a covered individual to pay an amount that is more than the payment amount limit under subsection (b) of this section.
Md. Code Ann., Ins. § 15-823 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–823LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Bone mass measurement” means a radiologic or radioisotopic procedure or other scientifically proven technology performed on a qualified individual for the purpose of identifying bone mass or detecting bone loss.
(3)
“Qualified individual” means:
(i)
an estrogen deficient individual at clinical risk for osteoporosis;
(ii)
an individual with a specific sign suggestive of spinal osteoporosis, including roentgenographic osteopenia or roentgenographic evidence suggestive of collapse, wedging, or ballooning of one or more thoracic or lumbar vertebral bodies, who is a candidate for therapeutic intervention or for an extensive diagnostic evaluation for metabolic bone disease;
(iii)
an individual receiving long–term glucocorticoid (steroid) therapy;
(iv)
an individual with primary hyperparathyroidism; or
(v)
an individual being monitored to assess the response to or efficacy of an approved osteoporosis drug therapy.
(b)
This section applies to:
(1)
each individual hospital or major medical insurance policy of an insurer that is delivered or issued for delivery in the State and is written on an expense–incurred basis;
(2)
each group or blanket health insurance policy of an insurer that is issued or delivered in the State and is written on an expense–incurred basis;
(3)
each individual or group medical or major medical contract or certificate of a nonprofit health service plan that is issued or delivered in the State and is written on an expense–incurred basis; and
(4)
each individual or group contract of a health maintenance organization that is issued or delivered in the State.
(c)
A policy, contract, or certificate subject to this section shall include coverage for qualified individuals for reimbursement for bone mass measurement for the prevention, diagnosis, and treatment of osteoporosis when the bone mass measurement is requested by a health care provider for the qualified individual.
Md. Code Ann., Ins. § 15-824 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–824LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Authorized prescriber” has the meaning stated in § 12-101 of the Health Occupations Article.
(3)
“Maintenance drug” means a drug anticipated to be required for 6 months or more to treat a chronic condition.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide coverage for drugs under health insurance policies or contracts that are delivered or issued for delivery in the State to employers or individuals on a group or individual basis; and
(2)
health maintenance organizations that provide coverage for drugs under contracts that are delivered or issued for delivery in the State to employers or individuals on a group or individual basis.
(c)
This section does not apply to an insured or enrollee who is a resident of a nursing home.
(d)
(1)
An entity subject to this section shall allow an insured or enrollee, if authorized by an authorized prescriber, to receive up to a 90-day supply of a maintenance drug in a single dispensing of the prescription.
(2)
The provisions of paragraph (1) of this subsection do not apply to the first prescription or change in a prescription for a maintenance drug that the authorized prescriber prescribes for the insured or enrollee.
(e)
Whenever an entity subject to this section increases the co-payment for a single dispensing of a prescription in a supply in excess of 30 days, the entity shall also proportionately increase the dispensing fee to the pharmacist for the prescription.
Md. Code Ann., Ins. § 15-825 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–825LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide inpatient hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide inpatient hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section shall provide coverage for the expenses incurred in conducting a medically recognized diagnostic examination which shall include a digital rectal exam and a blood test called the prostate–specific antigen (PSA) test:
(1)
for men who are between 40 and 75 years of age;
(2)
when used for the purpose of guiding patient management in monitoring the response to prostate cancer treatment;
(3)
when used for staging in determining the need for a bone scan in patients with prostate cancer; or
(4)
when used for male patients who are at high risk for prostate cancer.
(c)
Subject to federal guidance on the preventive care safe harbor for the absence of a preventive care deductible provided for under 26 U.S.C. § 223(c)(2)(C), an entity subject to this section may not apply a deductible, a copayment, or coinsurance to coverage for preventive care screening services for prostate cancer, which shall include a digital rectal exam and a blood test called the prostate–specific antigen (PSA) test in accordance with subsection (b) of this section.
Md. Code Ann., Ins. § 15-826 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–826LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide coverage for prescription drugs under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide coverage for prescription drugs under contracts that are issued or delivered in the State.
(b)
An entity subject to this section:
(1)
shall provide coverage for any contraceptive drug or device that is approved by the United States Food and Drug Administration for use as a contraceptive and that is obtained under a prescription written by an authorized prescriber as defined in § 12-101 of the Health Occupations Article;
(2)
shall provide coverage for the insertion or removal, and any medically necessary examination associated with the use, of such contraceptive drug or device; and
(3)
may not impose a different copayment or coinsurance for a contraceptive drug or device than is imposed for any other prescription.
(c)
(1)
A religious organization may request and an entity subject to this section shall grant the request for an exclusion from coverage under the policy, plan, or contract for the coverage required under subsection (b) of this section if the required coverage conflicts with the religious organization’s bona fide religious beliefs and practices.
(2)
A religious organization that obtains an exclusion under paragraph (1) of this subsection shall provide its employees reasonable and timely notice of the exclusion.
Md. Code Ann., Ins. § 15-826.1 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–826.1LinkCopy Citation
(a)
In this section, “authorized prescriber” has the meaning stated in § 12–101 of the Health Occupations Article.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide coverage for contraceptive drugs and devices under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide coverage for contraceptive drugs and devices under individual or group contracts that are issued or delivered in the State.
(c)
(1)
This subsection does not apply to a health benefit plan that is a grandfathered health plan, as defined in § 1251 of the Affordable Care Act.
(2)
An entity subject to this section:
(i)
except for a drug or device for which the U.S. Food and Drug Administration has issued a black box warning, may not apply a prior authorization requirement for a contraceptive drug or device that is:
(B)
an implantable rod;
(2)
approved by the U.S. Food and Drug Administration; and
(3)
obtained under a prescription written by an authorized prescriber; and
(ii)
except as provided in paragraph (3) of this subsection, may not apply a copayment or coinsurance requirement for a contraceptive drug or device that is:
(1)
approved by the U.S. Food and Drug Administration; and
(2)
obtained under a prescription written by an authorized prescriber.
(3)
An entity subject to this section may apply a copayment or coinsurance requirement for a contraceptive drug or device that, according to the U.S. Food and Drug Administration, is therapeutically equivalent to another contraceptive drug or device that is available under the same policy or contract without a copayment or coinsurance requirement.
(d)
(1)
An entity subject to this section shall provide coverage for a single dispensing to an insured or an enrollee of a supply of prescription contraceptives for up to a 12–month period.
(2)
Whenever an entity subject to this section increases the copayment for a single dispensing of a supply of prescription contraceptives for up to a 12–month period, the entity shall also increase proportionately the dispensing fee paid to the pharmacist.
(3)
This subsection may not be construed to require a provider to prescribe, furnish, or dispense 12 months of contraceptives at one time.
(e)
(1)
Subject to paragraph (2) of this subsection, an entity subject to this section:
(i)
shall provide coverage without a prescription for all contraceptive drugs approved by the U.S. Food and Drug Administration and available by prescription and over the counter; and
(ii)
may not apply a copayment or coinsurance requirement for a contraceptive drug dispensed without a prescription under item (i) of this paragraph that exceeds the copayment or coinsurance requirement for the contraceptive drug dispensed under a prescription.
(2)
An entity subject to this section:
(i)
may only be required to provide point–of–sale coverage under paragraph (1)(i) of this subsection at in–network pharmacies; and
(ii)
may limit the frequency with which the coverage required under paragraph (1)(i) of this subsection is provided.
Md. Code Ann., Ins. § 15-826.2 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–826.2LinkCopy Citation
(a)
(1)
In this subsection, “group” means a group that is not a group covered under a health insurance policy or contract or under a health maintenance organization contract issued or delivered to a small employer, as defined in § 31–101 of this article.
(2)
This subsection applies to:
(i)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide hospital, medical, or surgical benefits to groups under contracts that are issued or delivered in the State.
(3)
This subsection does not apply to an organization that requests and receives an exclusion from coverage under § 15–826(c) of this subtitle.
(4)
An entity subject to this subsection shall provide coverage for male sterilization.
(b)
(1)
This subsection applies to:
(i)
insurers and nonprofit health service plans that provide coverage for male sterilization under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for male sterilization under individual or group contracts that are issued or delivered in the State.
(2)
Except as provided in paragraph (3) of this subsection and except with respect to a health benefit plan that is a grandfathered health plan, as defined in § 1251 of the Affordable Care Act, an entity subject to this subsection may not apply a copayment, coinsurance requirement, or deductible to coverage for male sterilization.
(3)
If an insured or enrollee is covered under a high–deductible health plan, as defined in 26 U.S.C. § 223, an entity subject to this subsection may subject male sterilization to the deductible requirement of the high–deductible health plan.
Md. Code Ann., Ins. § 15-826.3 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–826.3LinkCopy Citation
(a)
In this section, “fertility awareness–based methods” means methods of identifying times of fertility and infertility by an individual to avoid pregnancy, including:
(1)
cervical mucus methods;
(2)
sympto–thermal or sympto–hormonal methods;
(3)
the standard days method; and
(4)
the lactational amenorrhea method.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section shall provide coverage for instruction by a licensed health care provider on fertility awareness–based methods.
(d)
Except with respect to a health benefit plan that is a grandfathered health plan, as defined in § 1251 of the Affordable Care Act, an entity subject to this section may not apply a copayment, coinsurance requirement, or deductible to the coverage required under this section.
Md. Code Ann., Ins. § 15-827 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–827LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Cooperative group” means a formal network of facilities that collaborate on research projects and have an established NIH-approved Peer Review Program operating within the group.
(ii)
“Cooperative group” includes:
(1)
the National Cancer Institute Clinical Cooperative Group;
(2)
the National Cancer Institute Community Clinical Oncology Program;
(3)
the AIDS Clinical Trials Group; and
(4)
the Community Programs for Clinical Research in AIDS.
(3)
“FDA” means the federal Food and Drug Administration.
(4)
“Member” means a policyholder, subscriber, insured, or certificate holder or a covered dependent of a policyholder, subscriber, insured, or certificate holder.
(5)
“Multiple project assurance contract” means a contract between an institution and the federal Department of Health and Human Services that defines the relationship of the institution to the federal Department of Health and Human Services and sets out the responsibilities of the institution and the procedures that will be used by the institution to protect human subjects.
(6)
“NIH” means the National Institutes of Health.
(7)
(i)
“Patient cost” means the cost of a medically necessary health care service that is incurred as a result of the treatment being provided to the member for purposes of the clinical trial.
(ii)
“Patient cost” does not include:
(1)
the cost of an investigational drug or device;
(2)
the cost of nonhealth care services that a patient may be required to receive as a result of the treatment being provided for purposes of the clinical trial;
(3)
costs associated with managing the research associated with the clinical trial; or
(4)
costs that would not be covered under the patient’s policy, plan, or contract for noninvestigational treatments.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, surgical, or pharmaceutical benefits to individuals or groups on an expense-incurred basis under a health insurance policy or contract issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, surgical, or pharmaceutical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
This section does not apply to a policy, plan, or contract paid for under Title XVIII or Title XIX of the Social Security Act.
(d)
A policy, plan, or contract subject to this section shall provide coverage for patient cost to a member in a clinical trial, as a result of:
(1)
treatment provided for a life-threatening condition; or
(2)
prevention, early detection, and treatment studies on cancer.
(e)
The coverage under subsection (d) of this section shall be required if:
(1)
(i)
the treatment is being provided or the studies are being conducted in a Phase I, Phase II, Phase III, or Phase IV clinical trial for cancer; or
(ii)
the treatment is being provided in a Phase I, Phase II, Phase III, or Phase IV clinical trial for any other life-threatening condition;
(2)
the treatment is being provided in a clinical trial approved by:
(i)
one of the National Institutes of Health;
(ii)
an NIH cooperative group or an NIH center;
(iii)
the FDA in the form of an investigational new drug application;
(iv)
the federal Department of Veterans Affairs; or
(v)
an institutional review board of an institution in the State which has a multiple project assurance contract approved by the Office of Protection from Research Risks of the National Institutes of Health;
(3)
the facility and personnel providing the treatment are capable of doing so by virtue of their experience, training, and volume of patients treated to maintain expertise;
(4)
there is no clearly superior, noninvestigational treatment alternative; and
(5)
the available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as the noninvestigational alternative.
(f)
In conjunction with the provisions of subsection (d) of this section, a policy, plan, or contract shall provide coverage for patient cost incurred for drugs and devices that have been approved for sale by the FDA whether or not the FDA has approved the drug or device for use in treating the patient’s particular condition, to the extent that the drugs or devices are not paid for by the manufacturer, distributor, or provider of that drug or device.
(g)
(1)
An entity seeking coverage for treatment in a clinical trial approved by an institutional review board under subsection (e)(2)(v) of this section shall post electronically and keep up-to-date a list of the clinical trials meeting the requirements of subsections (d) and (e) of this section.
(2)
The list shall include, for each clinical trial:
(i)
the phase for which the trial is approved;
(ii)
the entity approving the trial;
(iii)
whether the trial is for treatment of cancer or another life-threatening disease and, if not cancer, the particular disease; and
(iv)
the estimated number of participants in the trial.
(h)
This section may not be construed to affect compliance with § 15-804 of this subtitle regarding coverage for off-label use of drugs.
Md. Code Ann., Ins. § 15-828 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–828LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section shall provide coverage for general anesthesia and associated hospital or ambulatory facility charges in conjunction with dental care provided to an enrollee or insured if the enrollee or insured:
(1)
(i)
is 7 years of age or younger or is developmentally disabled;
(ii)
is an individual for whom a successful result cannot be expected from dental care provided under local anesthesia because of a physical, intellectual, or other medically compromising condition of the enrollee or insured; and
(iii)
is an individual for whom a superior result can be expected from dental care provided under general anesthesia; or
(2)
(i)
is an extremely uncooperative, fearful, or uncommunicative child who is 17 years of age or younger with dental needs of such magnitude that treatment should not be delayed or deferred; and
(ii)
is an individual for whom lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral or dental morbidity.
(c)
An entity subject to this section may require prior authorization for general anesthesia and associated hospital or ambulatory facility charges for dental care in the same manner that prior authorization is required for these benefits in connection with other covered medical care.
(d)
An entity subject to this section may restrict coverage for general anesthesia and associated hospital or ambulatory facility charges to dental care that is provided by:
(1)
a fully accredited specialist in pediatric dentistry;
(2)
a fully accredited specialist in oral and maxillofacial surgery; and
(3)
a dentist to whom hospital privileges have been granted.
(e)
The provisions of this section may not be construed to require coverage for the dental care for which the general anesthesia is provided.
(f)
The provisions of this section do not apply to dental care rendered for temporal mandibular joint disorders.
Md. Code Ann., Ins. § 15-829 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–829LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Chlamydia screening test” means any laboratory test that:
(i)
specifically detects for infection by one or more agents of chlamydia trachomatis; and
(ii)
is approved for this purpose by the federal Food and Drug Administration.
(3)
“Human papillomavirus screening test” means any laboratory test that:
(i)
specifically detects for infection by one or more agents of the human papillomavirus; and
(ii)
is approved for this purpose by the federal Food and Drug Administration.
(4)
“Multiple risk factors” means having a prior history of a sexually transmitted disease, new or multiple sex partners, inconsistent use of barrier contraceptives, or cervical ectopy.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section shall:
(1)
provide coverage for an annual routine chlamydia screening test for:
(i)
women who are:
(1)
under the age of 20 years if they are sexually active; and
(2)
at least 20 years old if they have multiple risk factors; and
(ii)
men who have multiple risk factors; and
(2)
provide coverage for a human papillomavirus screening at the testing intervals outlined in the recommendations for cervical cytology screening developed by the American College of Obstetricians and Gynecologists.
(d)
(1)
Subject to paragraph (2) of this subsection, the coverage required under this section may be subject to a copayment or coinsurance requirement or deductible that an entity subject to this section imposes for similar coverages under the same policy or contract.
(2)
The copayment or coinsurance requirement or deductible imposed under paragraph (1) of this subsection may not be greater than the copayment or coinsurance requirement or deductible imposed by the entity for similar coverages.
(e)
Nothing in this section may be construed to prohibit an entity subject to this section from providing coverages that are greater than or more favorable to an insured or enrollee than the coverage required under this section.
Md. Code Ann., Ins. § 15-830 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–830LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer that offers health insurance other than long–term care insurance or disability insurance;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization; or
(v)
except for a managed care organization as defined in Title 15, Subtitle 1 of the Health – General Article, any other person that provides health benefit plans subject to State regulation.
(3)
(i)
“Member” means an individual entitled to health care benefits under a policy or plan issued or delivered in the State by a carrier.
(ii)
“Member” includes a subscriber.
(4)
“Nonphysician specialist” means a health care provider:
(i)
(1)
who is not a physician;
(2)
who is licensed or certified under the Health Occupations Article; and
(3)
who is certified or trained to treat or provide health care services for a specified condition or disease in a manner that is within the scope of the license or certification of the health care provider; or
(ii)
that is licensed as a behavioral health program under § 7.5–401 of the Health – General Article.
(5)
(i)
“Provider panel” means the providers that contract with a carrier either directly or through a subcontracting entity to provide health care services to enrollees of the carrier.
(ii)
“Provider panel” does not include an arrangement in which any provider may participate solely by contracting with the carrier to provide health care services at a discounted fee–for–service rate.
(6)
“Specialist” means a physician who is certified or trained to practice in a specified field of medicine and who is not designated as a primary care provider by the carrier.
(b)
(1)
Each carrier that does not allow direct access to specialists shall establish and implement a procedure by which a member may receive a standing referral to a specialist in accordance with this subsection.
(2)
The procedure shall provide for a standing referral to a specialist if:
(i)
the primary care physician of the member determines, in consultation with the specialist, that the member needs continuing care from the specialist;
(ii)
the member has a condition or disease that:
(1)
is life threatening, degenerative, chronic, or disabling; and
(2)
requires specialized medical care; and
(iii)
the specialist:
(1)
has expertise in treating the life–threatening, degenerative, chronic, or disabling disease or condition; and
(2)
is part of the carrier’s provider panel.
(3)
Except as provided in subsection (c) of this section, a standing referral shall be made in accordance with a written treatment plan for a covered service developed by:
(i)
the primary care physician;
(ii)
the specialist; and
(iii)
the member.
(4)
A treatment plan may:
(i)
limit the number of visits to the specialist;
(ii)
limit the period of time in which visits to the specialist are authorized; and
(iii)
require the specialist to communicate regularly with the primary care physician regarding the treatment and health status of the member.
(5)
The procedure by which a member may receive a standing referral to a specialist may not include a requirement that a member see a provider in addition to the primary care physician before the standing referral is granted.
(c)
(1)
Notwithstanding any other provision of this section, a member who is pregnant shall receive a standing referral to an obstetrician in accordance with this subsection.
(2)
After the member who is pregnant receives a standing referral to an obstetrician, the obstetrician is responsible for the primary management of the member’s pregnancy, including the issuance of referrals in accordance with the carrier’s policies and procedures, through the postpartum period.
(3)
A written treatment plan may not be required when a standing referral is to an obstetrician under this subsection.
(d)
(1)
Each carrier shall establish and implement a procedure by which a member may request a referral to a specialist or nonphysician specialist who is not part of the carrier’s provider panel in accordance with this subsection.
(2)
The procedure shall provide for a referral to a specialist or nonphysician specialist who is not part of the carrier’s provider panel if:
(i)
(1)
the member is diagnosed with a condition or disease that requires specialized health care services or medical care; and
(2)
(A)
the carrier does not have in its provider panel a specialist or nonphysician specialist with the professional training and expertise to treat or provide health care services for the condition or disease; or
(B)
the carrier cannot provide reasonable access to a specialist or nonphysician specialist with the professional training and expertise to treat or provide health care services for the condition or disease without unreasonable delay or travel, including within the reasonable appointment waiting time and travel distance standards established in regulation for mental health and substance use disorder services; or
(ii)
(1)
the member is seeking mental health or substance use disorder care; and
(2)
the carrier cannot provide reasonable access to a specialist or nonphysician specialist within the reasonable appointment waiting time and travel distance standards established in regulation for mental health and substance use disorder services.
(3)
The procedure shall ensure that a request to obtain a referral to a specialist or nonphysician specialist who is not part of the carrier’s provider panel is addressed in a timely manner that is:
(i)
appropriate for the member’s condition; and
(ii)
in accordance with the timeliness requirements for determinations made by private review agents under § 15–10B–06 of this title.
(4)
If a member cannot access mental health or substance use disorder services through the referral requirements under paragraphs (2) and (3) of this subsection, the procedure shall require the carrier to provide additional assistance to the member in identifying and arranging coverage of mental health or substance use disorder services by a specialist or nonphysician specialist who is not part of the carrier’s provider panel.
(5)
If a carrier approves a member’s request for a referral made in accordance with this subsection, the carrier may not require utilization review other than what would be required if the covered benefit were provided by a provider on the carrier’s provider panel.
(6)
The procedure may not be used by a carrier as a substitute for establishing and maintaining a sufficient provider network in accordance with § 15–112 of this title.
(7)
Each carrier shall:
(i)
have a system in place that documents all requests to obtain a referral to receive a covered service from a specialist or nonphysician specialist who is not part of the carrier’s provider panel;
(ii)
inform members of the procedure to request a referral under paragraph (1) of this subsection; and
(iii)
provide the information documented under item (i) of this paragraph to the Commissioner on request.
(e)
(1)
Except as provided in paragraph (2) of this subsection, for purposes of calculating any deductible, copayment amount, or coinsurance payable by the member, a carrier shall treat services received in accordance with subsection (d) of this section as if the service was provided by a provider on the carrier’s provider panel.
(2)
A carrier shall ensure that services received in accordance with subsection (d) of this section for mental health or substance use disorders are provided for the duration of the treatment plan at no greater cost to the covered individual than if the covered benefit were provided by a provider on the carrier’s provider panel.
(f)
A decision by a carrier not to provide access to or coverage of treatment or health care services by a specialist or nonphysician specialist in accordance with this section constitutes an adverse decision as defined under Subtitle 10A of this title if the decision is based on a finding that the proposed service is not medically necessary, appropriate, or efficient.
(g)
(1)
Each carrier shall file with the Commissioner a copy of each of the procedures required under this section, including:
(i)
steps the carrier requires of a member to request a referral;
(ii)
the carrier’s timeline for decisions; and
(iii)
the carrier’s grievance procedures for denials.
(2)
Each carrier shall make a copy of each of the procedures filed under paragraph (1) of this subsection available to its members:
(i)
in the carrier’s online provider directory required under § 15–112(n)(1) of this title; and
(ii)
on request.
(h)
The Consumer Education and Advocacy Program, established under Title 2, Subtitle 3 of this article, in collaboration with the Health Education and Advocacy Unit of the Office of the Attorney General, shall provide public education to inform consumers of their procedures to request a referral to a specialist or nonphysician specialist as provided for in this section.
(i)
This section may not be construed to limit the provisions in § 19–710(p) of the Health – General Article.
Md. Code Ann., Ins. § 15-831 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–831LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Authorized prescriber” has the meaning stated in § 12–101 of the Health Occupations Article.
(3)
“Formulary” means a list of prescription drugs or devices that are covered by an entity subject to this section.
(4)
(i)
“Member” means an individual entitled to health care benefits for prescription drugs or devices under a policy issued or delivered in the State by an entity subject to this section.
(ii)
“Member” includes a subscriber.
(b)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs and devices under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for prescription drugs and devices under individual or group contracts that are issued or delivered in the State.
(2)
An insurer, nonprofit health service plan, or health maintenance organization that provides coverage for prescription drugs and devices through a pharmacy benefits manager is subject to the requirements of this section.
(3)
This section does not apply to a managed care organization as defined in § 15–101 of the Health – General Article.
(c)
Each entity subject to this section that limits its coverage of prescription drugs or devices to those in a formulary shall establish and implement a procedure by which a member may:
(1)
receive a prescription drug or device that is not in the entity’s formulary or has been removed from the entity’s formulary in accordance with this section; or
(2)
continue the same cost sharing requirements if the entity has moved the prescription drug or device to a higher deductible, copayment, or coinsurance tier.
(d)
The procedure shall provide for coverage for a prescription drug or device in accordance with subsection (c) of this section if, in the judgment of the authorized prescriber:
(1)
there is no equivalent prescription drug or device in the entity’s formulary in a lower tier;
(2)
an equivalent prescription drug or device in the entity’s formulary in a lower tier:
(i)
has been ineffective in treating the disease or condition of the member; or
(ii)
has caused or is likely to cause an adverse reaction or other harm to the member; or
(3)
for a contraceptive prescription drug or device, the prescription drug or device that is not on the formulary is medically necessary for the member to adhere to the appropriate use of the prescription drug or device.
(e)
A decision by an entity subject to this section not to provide access to or coverage of a prescription drug or device in accordance with this section constitutes an adverse decision as defined under Subtitle 10A of this title if the decision is based on a finding that the proposed drug or device is not medically necessary, appropriate, or efficient.
(f)
An entity subject to this section that removes a drug from its formulary or moves a prescription drug or device to a benefit tier that requires a member to pay a higher deductible, copayment, or coinsurance amount for the prescription drug or device shall provide a member who is currently on the prescription drug or device and the member’s health care provider with:
(1)
notice of the change at least 30 days before the change is implemented; and
(2)
in the notice required under item (1) of this subsection, the process for requesting an exemption through the procedure adopted in accordance with this section.
Md. Code Ann., Ins. § 15-832 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–832LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide inpatient hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide inpatient hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
For a patient who receives less than 48 hours of inpatient hospitalization following the surgical removal of a testicle, or who undergoes the surgical removal of a testicle on an outpatient basis, an entity subject to this section shall provide coverage for:
(1)
one home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility; and
(2)
an additional home visit if prescribed by the patient’s attending physician.
(c)
Each entity subject to this section shall provide notice annually to its enrollees and insureds about the coverage required under this section.
Md. Code Ann., Ins. § 15-832.1 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–832.1LinkCopy Citation
(a)
In this section, “mastectomy” means the surgical removal of all or part of a breast as a result of breast cancer.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide inpatient hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide inpatient hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section shall provide coverage for the cost of inpatient hospitalization services for a patient for a minimum of 48 hours following a mastectomy.
(d)
A patient may request a shorter length of stay than that provided in subsection (c) of this section if the patient decides, in consultation with the patient’s attending physician, that less time is needed for recovery.
(e)
(1)
For a patient who receives less than 48 hours of inpatient hospitalization following a mastectomy or who undergoes a mastectomy on an outpatient basis, an entity subject to this section shall provide coverage for:
(i)
one home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility; and
(ii)
an additional home visit if prescribed by the patient’s attending physician.
(2)
For a patient who remains in the hospital for at least the length of time provided under subsection (c) of this section, an entity subject to this section shall provide coverage for a home visit if prescribed by the attending physician.
(f)
An entity subject to this section may not deny, limit, or otherwise impair the participation of an attending physician under contract with the entity in providing health care services to enrollees or insureds for:
(1)
advocating the interest of a mastectomy patient through the entity’s utilization review or appeals system;
(2)
advocating more than 48 hours of inpatient hospital care for a patient with complications related to a mastectomy; or
(3)
prescribing a home visit under subsection (e)(1)(ii) or (2) of this section.
(g)
An entity subject to this section may not refuse reimbursement under subsection (e)(1) of this section if the services do not occur within the time specified.
(h)
An entity subject to this section shall provide notice annually to insureds and enrollees about the coverage provided by this section.
Md. Code Ann., Ins. § 15-833 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–833LinkCopy Citation
(a)
A policy will be considered to provide benefits on an expense-incurred basis if benefits payable under the policy are based on both medical expenses incurred and flat fees regardless of actual expenses incurred.
(b)
This section applies to health benefit plans issued under Subtitle 12 of this title.
(c)
This section does not apply if:
(1)
coverage is terminated because an individual fails to pay a required premium;
(2)
coverage is terminated for fraud or material misrepresentation by the individual; or
(3)
any coverage provided by a succeeding health benefit plan:
(i)
is provided at a cost to the individual that is less than or equal to the cost to the individual of the extended benefit required under this section; and
(ii)
does not result in an interruption of benefits.
(d)
During an extension period required under this section a premium may not be charged.
(e)
(1)
This subsection applies to:
(i)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits on an expense-incurred basis under group or blanket health insurance policies that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide hospital, medical, or surgical benefits under contracts that are issued or delivered in the State.
(2)
If an individual is totally disabled when the individual’s coverage terminates, an entity subject to this subsection shall continue to pay covered benefits, in accordance with the policy in effect at the time the individual’s coverage terminates, for expenses incurred by the individual for the condition causing the disability until the earlier of:
(i)
the date the individual ceases to be totally disabled; or
(ii)
12 months after the date coverage terminates.
(3)
An entity subject to this subsection may at any time require the individual to provide proof of total disability.
(f)
(1)
This subsection applies to:
(i)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits on an expense-incurred basis under individual health insurance policies that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide hospital, medical, or surgical benefits under individual contracts that are issued or delivered in the State.
(2)
If an individual has a claim in progress when the individual’s coverage terminates, an entity subject to this subsection shall continue to pay covered benefits, in accordance with the policy in effect at the time the individual’s coverage terminates, related to the claim until the earlier of:
(i)
the date the individual is released from the care of a physician for the condition that is the basis of the claim; or
(ii)
12 months after the date coverage terminates.
(g)
(1)
This subsection applies to:
(i)
group, blanket, and individual policies that limit coverage to hospital or surgical benefits on an expense-incurred basis; and
(ii)
group, blanket, and individual hospital indemnity policies.
(2)
If an individual is confined in a hospital on the date coverage terminates, a policy subject to this subsection shall continue to pay covered benefits, in accordance with the policy in effect at the time the individual’s coverage terminates, for the confinement until the earlier of:
(i)
the date the individual is discharged from the hospital; or
(ii)
12 months after the date coverage terminates.
(h)
(1)
This subsection applies to insurers, nonprofit health service plans, and health maintenance organizations that provide group, blanket, or individual vision benefits.
(2)
If an individual has ordered glasses or contact lenses before the date coverage terminates, an entity subject to this subsection that provides coverage for glasses or contact lenses shall continue to provide covered benefits, in accordance with the policy in effect at the time the individual’s coverage terminates, for the glasses or contact lenses if the individual receives the glasses or contact lenses within 30 days after the date of the order.
(i)
(1)
This subsection applies to insurers that provide group, blanket, or individual accidental death or dismemberment benefits.
(2)
An insurer subject to this subsection shall provide covered benefits, in accordance with the policy in effect at the time the individual’s coverage terminates, for a covered loss that occurs after the date coverage terminates if:
(i)
an accident occurs while the individual is covered; and
(ii)
the loss occurs within 90 days after the accident.
(j)
(1)
This subsection applies to insurers, nonprofit health service plans, health maintenance organizations, and dental plan organizations that provide group, blanket, or individual dental benefits.
(2)
Except as provided in paragraph (3) of this subsection, an entity subject to this subsection shall provide covered benefits, in accordance with the policy in effect at the time the individual’s coverage terminates, for a course of treatment for at least 90 days after the date coverage terminates if the treatment:
(i)
begins before the date coverage terminates; and
(ii)
requires two or more visits on separate days to a dentist’s office.
(3)
An entity subject to this subsection that provides coverage for orthodontics shall provide covered benefits, in accordance with the policy in effect at the time the individual’s coverage terminates, for orthodontics:
(i)
for 60 days after the date coverage terminates if the orthodontist has agreed to or is receiving monthly payments; or
(ii)
until the later of 60 days after the date coverage terminates or the end of the quarter in progress, if the orthodontist has agreed to accept or is receiving payments on a quarterly basis.
Md. Code Ann., Ins. § 15-834 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–834LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section shall provide coverage for a prosthesis that has been prescribed by a physician for an enrollee or insured who has undergone a mastectomy and has not had breast reconstruction.
Md. Code Ann., Ins. § 15-835 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–835LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Habilitative services” means services and devices, including occupational therapy, physical therapy, and speech therapy, that help a child keep, learn, or improve skills and functioning for daily living.
(3)
“Managed care system” means a method that an insurer, a nonprofit health service plan, or a health maintenance organization uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality, and claims.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
(1)
An entity subject to this section:
(i)
shall provide coverage of habilitative services for insureds and enrollees who are children until at least the end of the month in which the insured or enrollee turns 19 years old; and
(ii)
may do so through a managed care system.
(2)
An entity subject to this section is not required to provide reimbursement for habilitative services delivered through early intervention or school services.
(d)
An entity subject to this section shall provide notice annually to its insureds and enrollees about the coverage required under this section:
(1)
in print; and
(2)
on its Web site.
(e)
Beginning November 1, 2013, a determination by an entity subject to this section of whether habilitative services covered under this section are medically necessary and appropriate to treat autism and autism spectrum disorders shall be made in accordance with regulations adopted by the Commissioner.
Md. Code Ann., Ins. § 15-836 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–836LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide inpatient hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide inpatient hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
(1)
Subject to paragraph (2) of this subsection, an entity subject to this section shall provide, for an enrollee or insured whose hair loss results from chemotherapy or radiation treatment for cancer, coverage for one hair prosthesis.
(2)
The cost of a hair prosthesis required under paragraph (1) of this subsection may not exceed $350.
(c)
To be covered under this section, a hair prosthesis must be prescribed by the oncologist in attendance.
Md. Code Ann., Ins. § 15-837 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–837LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section shall provide coverage for colorectal cancer screening in accordance with the latest screening guidelines issued by the American Cancer Society.
(c)
(1)
Subject to paragraph (2) of this subsection, the coverage required under this section may be subject to a copayment or coinsurance requirement or deductible that an entity subject to this section imposes for similar coverages under the same policy or contract.
(2)
The copayment or coinsurance requirement or deductible imposed under paragraph (1) of this subsection may not be greater than the copayment or coinsurance requirement or deductible imposed by the entity for similar coverages.
(d)
Nothing in this section may be construed to prohibit an entity subject to this section from providing coverages that are greater than or more favorable to an insured or enrollee than the coverage required under this section.
Md. Code Ann., Ins. § 15-838 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–838LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
(1)
In this subsection, “hearing aid” means a device that:
(i)
is of a design and circuitry to optimize audibility and listening skills in the environment commonly experienced by children; and
(ii)
is nondisposable.
(2)
An entity subject to this section shall provide coverage for hearing aids for a minor child who is covered under a policy or contract if the hearing aids are prescribed, fitted, and dispensed by a licensed audiologist.
(3)
(i)
An entity subject to this section may limit the benefit payable under paragraph (2) of this subsection to $1,400 per hearing aid for each hearing–impaired ear every 36 months.
(ii)
An insured or enrolled individual may choose a hearing aid that is priced higher than the benefit payable under this subsection and may pay the difference between the price of the hearing aid and the benefit payable under this subsection, without financial or contractual penalty to the provider of the hearing aid.
(c)
This section does not prohibit an entity subject to this section from providing coverage that is greater or more favorable to an insured or enrolled individual than the coverage required under this section.
Md. Code Ann., Ins. § 15-838.1 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–838.1LinkCopy Citation
(a)
In this section, “hearing aid” means a device that:
(1)
is of a design and circuitry to optimize audibility and listening skills in the environment commonly experienced by adults; and
(2)
is nondisposable.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section shall provide coverage for all medically appropriate and necessary hearing aids for an adult who is covered under a policy or contract if the hearing aids are:
(1)
prescribed, fitted, and dispensed by a licensed audiologist; or
(2)
ordered, fitted, and dispensed by a licensed hearing aid dispenser.
(d)
(1)
An entity subject to this section may limit the benefit payable under subsection (c) of this section to $1,400 per hearing aid for each hearing–impaired ear every 36 months.
(2)
An insured or enrollee may choose a hearing aid that is priced higher than the benefit payable under this subsection and may pay the difference between the price of the hearing aid and the benefit payable under this subsection, without financial or contractual penalty to the provider of the hearing aid.
(e)
This section does not prohibit an entity subject to this section from providing coverage that is greater or more favorable to an insured or enrollee than the coverage required under this section.
Md. Code Ann., Ins. § 15-839 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–839LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Body mass index” means a practical marker that is used to assess the degree of obesity and is calculated by dividing the weight in kilograms by the height in meters squared.
(3)
“Morbid obesity” means a body mass index that is:
(i)
greater than 40 kilograms per meter squared; or
(ii)
equal to or greater than 35 kilograms per meter squared with a comorbid medical condition, including hypertension, a cardiopulmonary condition, sleep apnea, or diabetes.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State;
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State; and
(3)
managed care organizations, as defined in § 15-101 of the Health - General Article.
(c)
An entity subject to this section shall provide coverage for the surgical treatment of morbid obesity that is:
(1)
recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity; and
(2)
consistent with guidelines approved by the National Institutes of Health.
(d)
An entity subject to this section shall provide the benefits required under this section to the same extent as for other medically necessary surgical procedures under the enrollee’s or insured’s contract or policy with the entity.
Md. Code Ann., Ins. § 15-840 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–840LinkCopy Citation
(a)
In this section, “residential crisis services” means intensive mental health and support services that are:
(1)
provided to a child or an adult with a mental illness who is experiencing or is at risk of a psychiatric crisis that would impair the individual’s ability to function in the community;
(2)
designed to prevent a psychiatric inpatient admission, provide an alternative to psychiatric inpatient admission, or shorten the length of inpatient stay;
(3)
provided out of the individual’s residence on a short–term basis in a community–based residential setting; and
(4)
provided by entities that are licensed by the Maryland Department of Health to provide residential crisis services.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
(1)
An entity subject to this section shall provide coverage for medically necessary residential crisis services.
(2)
The services required under this section may be delivered under a managed care system.
Md. Code Ann., Ins. § 15-841 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–841LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Authorized prescriber” has the meaning stated in § 12-101 of the Health Occupations Article.
(3)
(i)
“Nicotine replacement therapy” means a product that:
(1)
is used to deliver nicotine to an individual attempting to cease the use of tobacco products; and
(2)
is obtained under a prescription written by an authorized prescriber.
(ii)
“Nicotine replacement therapy” does not include any over-the-counter product that may be obtained without a prescription.
(4)
“Tobacco product” has the meaning stated in § 10-101 of the Criminal Law Article.
(b)
(1)
This subsection applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs to individuals or groups under health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for prescription drugs to individuals or groups under contracts that are issued or delivered in the State.
(2)
An entity subject to this subsection shall provide coverage for:
(i)
except for a drug that may be obtained over-the-counter without a prescription, any drug that:
(1)
is approved by the United States Food and Drug Administration as an aid for the cessation of the use of tobacco products; and
(2)
is obtained under a prescription written by an authorized prescriber; and
(ii)
two 90-day courses of nicotine replacement therapy during each policy year.
(3)
An entity subject to this subsection may not impose a different copayment or coinsurance requirement for a drug or nicotine replacement therapy provided under paragraph (2) of this subsection than is imposed for any other comparable prescription.
Md. Code Ann., Ins. § 15-842 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–842LinkCopy Citation
(a)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs and devices under health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for prescription drugs and devices under contracts that are issued or delivered in the State.
(2)
An insurer, nonprofit health service plan, or health maintenance organization that provides coverage for prescription drugs and devices through a pharmacy benefits manager is subject to the requirements of this section.
(b)
An entity subject to this section may not impose a copayment or coinsurance requirement for a covered prescription drug or device that exceeds the retail price of the prescription drug or device.
Md. Code Ann., Ins. § 15-843 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–843LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, and surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
(1)
Subject to paragraph (2) of this subsection, a policy or plan subject to this section shall include, under the family member coverage, coverage for amino acid–based elemental formula, regardless of delivery method, for the diagnosis and treatment of:
(i)
Immunoglobulin E and non–Immunoglobulin E mediated allergies to multiple food proteins;
(ii)
severe food protein induced enterocolitis syndrome;
(iii)
eosinophilic disorders, as evidenced by the results of a biopsy; and
(iv)
impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.
(2)
Subject to paragraph (3) of this subsection, the coverage required under paragraph (1) of this subsection is required if the ordering physician has issued a written order stating that the amino acid–based elemental formula is medically necessary for the treatment of a disease or disorder listed in paragraph (1) of this subsection.
(3)
In accordance with Subtitle 10A of this title, a private review agent, acting on behalf of an insurer, nonprofit health service plan, or health maintenance organization, may review the ordering physician’s determination of the medical necessity of the amino acid–based elemental formula for the treatment of a disease or disorder listed in paragraph (1) of this subsection.
Md. Code Ann., Ins. § 15-844 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–844LinkCopy Citation
(a)
(1)
In this section, “prosthesis” means an artificial device to replace, in whole or in part, a leg, an arm, or an eye.
(2)
“Prosthesis” includes a custom–designed, –fabricated, –fitted, or –modified device to treat partial or total limb loss for purposes of restoring physiological function.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section shall provide once annually coverage for:
(1)
prostheses;
(2)
components of prostheses;
(3)
repairs to prostheses; and
(4)
subject to subsection (d) of this section, replacements of prostheses or prosthesis components.
(d)
(1)
An entity subject to this section shall provide coverage for replacements of prostheses if an ordering health care provider determines that the provision of a replacement prosthesis or a component of the prosthesis is necessary:
(i)
because of a change in the physiological condition of the patient;
(ii)
unless necessitated by misuse, because of an irreparable change in the condition of the prosthesis or a component of the prosthesis; or
(iii)
unless necessitated by misuse, because the condition of the prosthesis or the component of the prosthesis requires repairs and the cost of the repairs would be more than 60% of the cost of replacing the prosthesis or the component of the prosthesis.
(2)
An entity subject to this section may require an ordering health care provider to confirm that the prosthesis or component of the prosthesis being replaced meets the requirements of paragraph (1) of this subsection if the prosthesis or component is less than 3 years old.
(e)
The covered benefits under this section may not be subject to a higher copayment or coinsurance requirement than the copayment or coinsurance for other similar medical and surgical benefits covered under the policy or contract of the insured or enrollee.
(f)
An entity subject to this section may not impose an annual or lifetime dollar maximum on coverage required under this section separate from any annual or lifetime dollar maximum that applies in the aggregate to all covered benefits under the policy or contract of the insured or enrollee.
(g)
(1)
An entity subject to this section may not establish requirements for medical necessity or appropriateness for the coverage required under this section that are more restrictive than the indications and limitations of coverage and medical necessity established under the Medicare Coverage Database.
(2)
The covered benefits under this section include prostheses determined by a treating health care provider to be medically necessary for:
(i)
completing activities of daily living;
(ii)
essential job–related activities; or
(iii)
performing physical activities, including running, biking, swimming, strength training, and other activities to maximize the whole–body health and lower or upper limb function of the insured or enrollee.
(h)
An entity subject to this section that uses a provider panel for a policy or contract described in subsection (b) of this section and the provision of covered benefits under this section shall comply with § 15–112(b)(3) of this title.
Md. Code Ann., Ins. § 15-845 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–845LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide coverage for prescription eye drops under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide coverage for prescription eye drops under contracts that are issued or delivered in the State.
(b)
An entity subject to this section shall provide coverage for a refill of prescription eye drops:
(1)
in accordance with guidance for early refills of topical ophthalmic products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services; and
(2)
if:
(i)
the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed;
(ii)
the refill requested by the insured does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner; and
(iii)
the prescription eye drops prescribed by the health care practitioner are a covered benefit under the policy or contract of the insured.
Md. Code Ann., Ins. § 15-846 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–846LinkCopy Citation
(a)
In this section, “cancer chemotherapy” means medication that is prescribed by a licensed physician to kill or slow the growth of cancer cells.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide coverage for both orally administered cancer chemotherapy and cancer chemotherapy that is administered intravenously or by injection under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide coverage for both orally administered cancer chemotherapy and cancer chemotherapy that is administered intravenously or by injection under contracts that are issued or delivered in the State.
(c)
An entity subject to this section may not impose dollar limits, copayments, deductibles, or coinsurance requirements on coverage for orally administered cancer chemotherapy that are less favorable to an insured or enrollee than the dollar limits, copayments, deductibles, or coinsurance requirements that apply to coverage for cancer chemotherapy that is administered intravenously or by injection.
(d)
An entity subject to this section may not reclassify cancer chemotherapy or increase a copayment, deductible, coinsurance requirement, or other out–of–pocket expense imposed on cancer chemotherapy to achieve compliance with this section.
Md. Code Ann., Ins. § 15-847 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–847LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Complex or chronic medical condition” means a physical, behavioral, or developmental condition that:
(1)
may have no known cure;
(2)
is progressive; or
(3)
can be debilitating or fatal if left untreated or undertreated.
(ii)
“Complex or chronic medical condition” includes:
(1)
multiple sclerosis;
(2)
hepatitis C; and
(3)
rheumatoid arthritis.
(3)
“Managed care system” means a system of cost containment methods that an insurer, a nonprofit health service plan, or a health maintenance organization uses to review and preauthorize drugs prescribed by a health care provider for a covered individual to control utilization, quality, and claims.
(4)
(i)
“Rare medical condition” means a disease or condition that affects fewer than:
(1)
200,000 individuals in the United States; or
(2)
approximately 1 in 1,500 individuals worldwide.
(ii)
“Rare medical condition” includes:
(1)
cystic fibrosis;
(2)
hemophilia; and
(3)
multiple myeloma.
(5)
(i)
“Specialty drug” means a prescription drug that:
(1)
is prescribed for an individual with a complex or chronic medical condition or a rare medical condition;
(2)
costs $600 or more for up to a 30–day supply;
(3)
is not typically stocked at retail pharmacies; and
(4)
(A)
requires a difficult or unusual process of delivery to the patient in the preparation, handling, storage, inventory, or distribution of the drug; or
(B)
requires enhanced patient education, management, or support, beyond those required for traditional dispensing, before or after administration of the drug.
(ii)
“Specialty drug” does not include a prescription drug prescribed to treat diabetes, HIV, or AIDS.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide coverage for prescription drugs under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide coverage for prescription drugs under individual or group contracts that are issued or delivered in the State.
(c)
(1)
Subject to paragraph (2) of this subsection, an entity subject to this section may not impose a copayment or coinsurance requirement on a covered specialty drug that exceeds $150 for up to a 30–day supply of the specialty drug.
(2)
On July 1 of each year, the limit on the copayment or coinsurance requirement on a covered specialty drug shall increase by a percentage equal to the percentage change from the preceding year in the medical care component of the March Consumer Price Index for All Urban Consumers, Washington Metropolitan Area, from the U.S. Department of Labor, Bureau of Labor Statistics.
(d)
Subject to subsection (h) of this section and § 15–805 of this subtitle, notwithstanding § 15–806 of this subtitle, and except as provided in § 15–847.2 of this subtitle, this article or regulations adopted under this article do not preclude an entity subject to this section from requiring a covered specialty drug to be obtained through:
(1)
a designated pharmacy or other source authorized under the Health Occupations Article to dispense or administer prescription drugs; or
(2)
a pharmacy participating in the entity’s provider network, if the entity determines that the pharmacy:
(i)
meets the entity’s performance standards; and
(ii)
accepts the entity’s network reimbursement rates.
(e)
(1)
A pharmacy registered under § 340B of the federal Public Health Services Act may apply to an entity subject to this section to be a designated pharmacy under subsection (d)(1) of this section for the purpose of enabling the pharmacy’s patients with hepatitis C to receive the copayment or coinsurance maximum provided for in subsection (c) of this section if:
(i)
the pharmacy is owned by a federally qualified health center, as defined in 42 U.S.C. § 254B;
(ii)
the federally qualified health center provides integrated and coordinated medical and pharmaceutical services to hepatitis C patients; and
(iii)
the prescription drugs are covered specialty drugs for the treatment of hepatitis C.
(2)
An entity subject to this section may not unreasonably withhold approval of a pharmacy’s application under paragraph (1) of this subsection.
(f)
An entity subject to this section may provide coverage for specialty drugs through a managed care system.
(g)
(1)
A determination by an entity subject to this section that a prescription drug is not a specialty drug is considered a coverage decision under § 15–10D–01 of this title.
(2)
For complaints filed with the Commissioner under this subsection, if the entity made its determination that a prescription drug is not a specialty drug on the basis that the prescription drug did not meet the criteria listed in subsection (a)(5)(i) of this section:
(i)
the Commissioner may seek advice from an independent review organization or medical expert on the list compiled under § 15–10A–05(b) of this title; and
(ii)
the expenses for any advice provided by an independent review organization or medical expert shall be paid for as provided under § 15–10A–05(h) of this title.
(h)
This section may not be construed to supersede the authority of the Health Services Cost Review Commission to set rates for specialty drugs administered to patients in a setting regulated by the Health Services Cost Review Commission.
Md. Code Ann., Ins. § 15-847.1 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–847.1LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide coverage for prescription drugs under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide coverage for prescription drugs under individual group contracts that are issued or delivered in the State.
(b)
(1)
Subject to paragraph (2) of this subsection and § 15–822.1 of this subtitle, an entity subject to this section may not impose a copayment or coinsurance requirement on a prescription drug prescribed to treat diabetes, HIV, or AIDS that exceeds $150 for up to a 30–day supply of the drug.
(2)
On July 1 each year, the limit on the copayment or coinsurance requirement on a prescription drug prescribed to treat diabetes, HIV, or AIDS shall increase by a percentage equal to the percentage change from the preceding year in the medical care component of the March Consumer Price Index for All Urban Consumers, Washington Metropolitan Area, from the U.S. Department of Labor, Bureau of Labor Statistics.
Md. Code Ann., Ins. § 15-847.2 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–847.2LinkCopy Citation
(a)
In this section, “specialty drug” has the meaning stated in § 15–847 of this subtitle.
(b)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for prescription drugs under individual or group contracts that are issued or delivered in the State.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for prescription drugs through a pharmacy benefits manager is subject to the requirements of this section.
(c)
An entity subject to this section may not exclude coverage for a covered specialty drug administered or dispensed by a provider under § 12–102 of the Health Occupations Article if the entity determines that:
(1)
the provider that administers or dispenses the covered specialty drug:
(i)
is an in–network provider of covered oncology services; and
(ii)
complies with State regulations for the administering and dispensing of specialty drugs; and
(2)
the covered specialty drug is:
(i)
auto–injected or an oral targeted immune modulator; or
(ii)
an oral medication that:
(1)
requires complex dosing based on clinical presentation; or
(2)
is used concomitantly with other infusion or radiation therapies.
(d)
(1)
Subject to subsection (f) of this section, the reimbursement rate for specialty drugs covered under this section shall be:
(i)
agreed to by the covered, in–network provider and the entity subject to this section; and
(ii)
billed at a nonhospital level of care or place of service.
(2)
Unless otherwise agreed to by the covered, in–network provider and the entity subject to this section, the reimbursement rate for specialty drugs covered under this section may not exceed the rate applicable to a designated specialty pharmacy for dispensing the covered specialty drugs.
(e)
This section does not prohibit an entity subject to this section from refusing to authorize or approve or from denying coverage for a covered specialty drug administered or dispensed by a provider if administering or dispensing the drug fails to satisfy medical necessity criteria.
(f)
This section may not be construed to supersede the authority of the Health Services Cost Review Commission to set rates for specialty drugs administered to patients in a setting regulated by the Health Services Cost Review Commission.
Md. Code Ann., Ins. § 15-848 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–848LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
This section does not apply to a policy or contract issued or delivered by an entity subject to this section that provides the essential health benefits required under § 1302(a) of the Affordable Care Act.
(c)
An entity subject to this section shall provide coverage for all medically appropriate and necessary equipment and supplies used for the treatment of ostomies, including flanges, collection bags, clamps, irrigation devices, sanitizing products, ostomy rings, ostomy belts, and catheters used for drainage of urostomies.
(d)
(1)
Subject to paragraph (2) of this subsection, the coverage required under this section may be subject to the annual deductibles or coinsurance requirements imposed by an entity subject to this section for similar coverages under the same health insurance policy or contract.
(2)
The annual deductibles or coinsurance requirements imposed under paragraph (1) of this subsection for the coverage required under this section may not be greater than the annual deductibles or coinsurance requirements imposed by the entity for similar coverages.
Md. Code Ann., Ins. § 15-849 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–849LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Abuse–deterrent opioid analgesic drug product” means a brand name or generic opioid analgesic drug product approved by the U.S. Food and Drug Administration with abuse–deterrent labeling that indicates the drug product is expected to result in a meaningful reduction in abuse.
(3)
“Opioid analgesic drug product” means a drug product that contains an opioid agonist and is indicated by the U.S. Food and Drug Administration for the treatment of pain, regardless of whether the drug product:
(i)
is in immediate release or extended release form; or
(ii)
contains other drug substances.
(b)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for prescription drugs under individual or group contracts that are issued or delivered in the State.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for prescription drugs through a pharmacy benefits manager is subject to the requirements of this section.
(c)
(1)
An entity subject to this section shall provide coverage for:
(i)
at least two brand name abuse–deterrent opioid analgesic drug products, each containing different analgesic ingredients, on the lowest cost tier for brand name prescription drugs on the entity’s formulary for prescription drug coverage; and
(ii)
if available, at least two generic abuse–deterrent opioid analgesic drug products, each containing different analgesic ingredients, on the lowest cost tier for generic drugs on the entity’s formulary for prescription drug coverage.
(2)
An entity subject to this section may not require an insured or an enrollee to first use an opioid analgesic drug product without abuse–deterrent labeling before providing coverage for an abuse–deterrent opioid analgesic drug product covered on the entity’s formulary for prescription drug coverage.
(d)
Notwithstanding subsection (c)(2) of this section, an entity subject to this section may undertake utilization review, including preauthorization, for an abuse–deterrent opioid analgesic drug product covered by the entity, if the same utilization review requirements are applied to non–abuse–deterrent opioid analgesic drug products covered by the entity in the same formulary tier as the abuse–deterrent opioid analgesic product.
Md. Code Ann., Ins. § 15-850 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–850LinkCopy Citation
(a)
In this section, “opioid antagonist” means:
(1)
naloxone hydrochloride; or
(2)
any other similarly acting and equally safe drug approved by the federal Food and Drug Administration for the treatment of a drug overdose.
(b)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for prescription drugs under individual or group contracts that are issued or delivered in the State.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for prescription drugs through a pharmacy benefits manager is subject to the requirements of this section.
(c)
An entity subject to this section that includes on its formulary an opioid antagonist may apply a prior authorization requirement for an opioid antagonist only if the entity provides coverage for at least one formulation of the opioid antagonist without a prior authorization requirement.
Md. Code Ann., Ins. § 15-851 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–851LinkCopy Citation
(a)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for substance use disorder benefits or prescription drugs under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for substance use disorder benefits or prescription drugs under individual or group contracts that are issued or delivered in the State.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for substance use disorder benefits under the medical benefit or for prescription drugs through a pharmacy benefits manager is subject to the requirements of this section.
(b)
An entity subject to this section may not apply a prior authorization requirement for a prescription drug:
(1)
when used for treatment of an opioid use disorder; and
(2)
that contains methadone, buprenorphine, or naltrexone.
Md. Code Ann., Ins. § 15-852 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–852LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“In–network pharmacy” means a pharmacy that is among the participating providers with which an entity subject to this section contracts to provide health care services to members.
(3)
“Member” means an individual entitled to health care benefits for prescription drugs or devices under a policy issued or delivered in the State by an entity subject to this section.
(b)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs and devices under health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for prescription drugs and devices under contracts that are issued or delivered in the State.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for prescription drugs and devices through a pharmacy benefits manager is subject to the requirements of this section.
(c)
An entity subject to this section shall allow and apply a prorated daily copayment or coinsurance amount for a partial supply of a prescription drug dispensed by an in–network pharmacy if:
(1)
the prescriber or the pharmacist determines dispensing a partial supply of a prescription drug to be in the best interest of the member;
(2)
the prescription drug is anticipated to be required for more than 3 months;
(3)
the member requests or agrees to a partial supply for the purpose of synchronizing the dispensing of the member’s prescription drugs;
(4)
the prescription drug is not a Schedule II controlled dangerous substance; and
(5)
the supply and dispensing of the prescription drug meets all prior authorization and utilization management requirements specific to the prescription drug at the time of the synchronized dispensing.
(d)
Subject to subsection (c) of this section, an entity subject to this section:
(1)
may not deny payment of benefits to an in–network pharmacy for a covered prescription drug solely on the basis that only a partial supply of the prescription drug was dispensed; and
(2)
shall allow an in–network pharmacy to override any denial codes indicating that a prescription is being refilled too soon.
(e)
Subject to subsection (c) of this section, an entity subject to this section:
(1)
may not use a payment structure that incorporates prorated dispensing fees for dispensing a partial supply of a prescription drug; and
(2)
shall pay an in–network pharmacy a full dispensing fee for dispensing a partial supply of a prescription drug under this section, regardless of:
(i)
any prorated copayment or coinsurance amount charged to a member; or
(ii)
any fee paid to the pharmacy for synchronizing a member’s prescriptions.
Md. Code Ann., Ins. § 15-853 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–853LinkCopy Citation
(a)
(1)
In this section, “gradient compression garment” means a garment that:
(i)
is used for the treatment of lymphedema;
(ii)
requires a prescription; and
(iii)
is custom fit for the individual for whom the garment is prescribed.
(2)
“Gradient compression garment” does not include disposable medical supplies, including over–the–counter compression or elastic knee–high or other stocking products.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section shall provide coverage for the medically necessary diagnosis, evaluation, and treatment of lymphedema, including equipment, supplies, complex decongestive therapy, gradient compression garments, and self–management training and education.
(d)
(1)
Subject to paragraph (2) of this subsection, the coverage required under this section may be subject to the annual deductibles, copayments, or coinsurance requirements imposed by an entity subject to this section for similar coverages under the same health insurance policy or contract.
(2)
The annual deductibles, copayments, or coinsurance requirements imposed under paragraph (1) of this subsection for the coverage required under this section may not be greater than the annual deductibles, copayments, or coinsurance requirements imposed by the entity for similar coverages.
Md. Code Ann., Ins. § 15-854 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–854LinkCopy Citation
(a)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs through a pharmacy benefit under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for prescription drugs through a pharmacy benefit under individual or group contracts that are issued or delivered in the State.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for prescription drugs through a pharmacy benefits manager or that contracts with a private review agent under Subtitle 10B of this title is subject to the requirements of this section.
(3)
This section does not apply to a managed care organization as defined in § 15–101 of the Health – General Article.
(b)
(1)
(i)
If an entity subject to this section requires a prior authorization for a prescription drug, the prior authorization request shall allow a health care provider to indicate whether a prescription drug is to be used to treat a chronic condition.
(ii)
If a health care provider indicates that the prescription drug is to treat a chronic condition, an entity subject to this section may not request a reauthorization for a repeat prescription for the prescription drug for 1 year or for the standard course of treatment for the chronic condition being treated, whichever is less.
(2)
For a prior authorization that is filed electronically, the entity shall maintain a database that will prepopulate prior authorization requests with an insured’s available insurance and demographic information.
(c)
(1)
On receipt of information documenting a prior authorization from the insured or from the insured’s health care provider, an entity subject to this section shall honor a prior authorization granted to an insured from a previous entity for at least the lesser of 90 days or the length of the course of treatment.
(2)
During the time period described in paragraph (1) of this subsection, an entity may perform its own review to grant a prior authorization for the prescription drug.
(d)
(1)
An entity subject to this section shall honor a prior authorization issued by the entity for a prescription drug and may not require a health care provider to submit a request for another prior authorization for the prescription drug:
(i)
if the insured changes health benefit plans that are both covered by the same entity and the prescription drug is a covered benefit under the current health benefit plan; or
(ii)
except as provided in paragraph (2) of this subsection, when the dosage for the approved prescription drug changes and the change is consistent with federal Food and Drug Administration labeled dosages.
(2)
Except as provided in § 15–851 of this subtitle, an entity may require a prior authorization for a change in dosage for an opioid under this subsection.
(e)
(1)
If an entity under this section implements a new prior authorization requirement for a prescription drug, the entity shall provide notice of the new requirement at least 60 days before the implementation of a new prior authorization requirement:
(i)
in writing to any insured who is prescribed the prescription drug; and
(ii)
either in writing or electronically to all contracted health care providers.
(2)
The notice required under paragraph (1) of this subsection shall indicate that the insured may remain on the prescription drug at the time of reauthorization in accordance with subsection (g) of this section.
(f)
(1)
Except as provided in paragraph (2) of this subsection, an entity subject to this section may not require more than one prior authorization if two or more tablets of different dosage strengths of the same prescription drug are:
(i)
prescribed at the same time as part of an insured’s treatment plan; and
(ii)
manufactured by the same manufacturer.
(2)
This subsection does not prohibit an entity from requiring more than one prior authorization if the prescription is for two or more tablets of different dosage strengths of an opioid that is not an opioid partial agonist.
(g)
(1)
An entity subject to this section may not issue an adverse decision on a reauthorization for the same prescription drug or request additional documentation from the prescriber for the reauthorization request if:
(i)
the prescription drug is:
(1)
an immune globulin (human) as defined in 21 C.F.R. § 640.100; or
(2)
used for the treatment of a mental disorder listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association;
(ii)
the entity previously approved a prior authorization for the prescription drug for the insured;
(iii)
the insured has been treated with the prescription drug without interruption since the initial approval of the prior authorization; and
(iv)
the prescriber attests that, based on the prescriber’s professional judgment, the prescription drug continues to be necessary to effectively treat the insured’s condition.
(2)
If the prescription drug that is being requested has been removed from the formulary or has been moved to a higher deductible, copayment, or coinsurance tier, the entity shall provide the insured and insured’s health care provider the information required under § 15–831 of this subtitle.
Md. Code Ann., Ins. § 15-854.1 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–854.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Active course of treatment” means a course of treatment for which an insured is actively seeing a health care provider and following the course of treatment.
(3)
“Course of treatment” means treatment that:
(i)
is prescribed to treat or ordered for the treatment of an insured with a specific condition;
(ii)
is outlined and agreed to by the insured and the health care provider before the treatment begins; and
(iii)
may be part of a treatment plan.
(b)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization that contracts with a private review agent under Subtitle 10B of this title is subject to the requirements of this section.
(3)
An insurer, a nonprofit health service plan, or a health maintenance organization that contracts with a third party to dispense medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction is subject to the requirements of this section.
(c)
(1)
Notwithstanding § 15–854 of this subtitle as it applies to coverage for prescription drugs, an entity subject to this section shall approve a request for the prior authorization of a course of treatment, including for chronic conditions, rehabilitative services, substance use disorders, and mental health conditions, that is:
(i)
for a period of time that is as long as necessary to avoid disruptions in care; and
(ii)
determined in accordance with applicable coverage criteria, the insured’s medical history, and the health care provider’s recommendation.
(2)
For new enrollees, an entity subject to this section may not disrupt or require reauthorization for an active course of treatment for covered services for at least 90 days after the date of enrollment.
Md. Code Ann., Ins. § 15-855 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–855LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section shall provide coverage for medically necessary diagnosis, evaluation, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome, including the use of intravenous immunoglobulin therapy.
(c)
(1)
Subject to paragraph (2) of this subsection, the coverage required under this section may be subject to the annual deductibles, copayments, or coinsurance requirements imposed by an entity subject to this section for similar coverages under the same health insurance policy or contract.
(2)
The annual deductibles, copayments, or coinsurance requirements imposed under paragraph (1) of this subsection for the coverage required under this section may not be greater than the annual deductibles, copayments, or coinsurance requirements imposed by the entity for similar coverages.
(d)
(1)
Except as provided for in paragraph (2) of this subsection, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome shall be coded as autoimmune encephalitis for billing and diagnosis purposes.
(2)
If the American Medical Association and the Centers for Medicare and Medicaid Services create and assign a specific code for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections or pediatric acute onset neuropsychiatric syndrome for billing and diagnosis purposes, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome may be coded as:
(i)
autoimmune encephalitis;
(ii)
pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections; or
(iii)
pediatric acute onset neuropsychiatric syndrome.
Md. Code Ann., Ins. § 15-856 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–856LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“COVID–19” means, interchangeably and collectively, the coronavirus known as COVID–19 or 2019–nCoV and the SARS–CoV–2 virus.
(3)
(i)
“COVID–19 test” means an in vitro diagnostic test for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19, as described in § 3201 of the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act.
(ii)
“COVID–19 test” includes a federal Food and Drug Administration–approved, cleared, or authorized rapid point–of–care test and an at–home collection test for the detection or diagnosis of COVID–19.
(4)
“Health benefit plan”:
(i)
for a small employer plan, has the meaning stated in § 15–1201 of this title; and
(ii)
for an individual plan, has the meaning stated in § 15–1301 of this title.
(5)
(i)
“Member” means an individual entitled to health care benefits under a policy issued or delivered in the State by an entity subject to this section.
(ii)
“Member” includes a subscriber.
(b)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(2)
This section applies to each individual and small employer health benefit plan that is issued or delivered in the State by an insurer, a nonprofit health service plan, or a health maintenance organization, irrespective of §§ 15–1207(d) and 31–116 of this article.
(c)
An entity subject to this section shall provide coverage for COVID–19 tests and related items and services for the administration of COVID–19 tests, including facility fees, health care practitioner fees, and evaluation of the member for purposes of determining the need for the COVID–19 test, as required by the Families First Coronavirus Response Act, the Coronavirus Aid, Relief, and Economic Security (CARES) Act, and any applicable federal regulations or guidance.
(d)
An entity subject to this section may not apply a copayment, coinsurance requirement, or deductible to coverage for COVID–19 tests and related items and services for the administration of COVID–19 tests.
Md. Code Ann., Ins. § 15-857 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–857LinkCopy Citation
(a)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide labor and delivery coverage to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide labor and delivery coverage to individuals or groups under contracts that are issued or delivered in the State.
(2)
This section does not apply to a multistate plan that does not provide coverage for abortions in accordance with 42 U.S.C. § 18054(a)(6).
(3)
An organization that is eligible to obtain an exclusion from the coverage requirements under § 15–826 of this subtitle may obtain from an entity subject to this section an exclusion from the coverage and notice requirements of this section if the requirements conflict with the organization’s bona fide religious beliefs and practices.
(b)
Except as provided in subsection (c) or (d) of this section and notwithstanding § 31–116(a) of this article, an entity subject to this section shall:
(1)
cover abortion care services without:
(i)
a deductible, coinsurance, copayment, or any other cost–sharing requirement; and
(ii)
restrictions that are inconsistent with the protected rights under Title 20, Subtitle 2 of the Health – General Article; and
(2)
provide information to consumers about abortion care coverage using the terminology “abortion care” to describe coverage.
(c)
If the Commissioner determines that enforcement of this section may adversely affect the allocation of federal funds to the State, the Commissioner may grant an exemption to the requirements of this section to the minimum extent necessary to ensure the continued receipt of federal funds.
(d)
A high–deductible plan, as defined in 26 U.S.C. § 223(c)(2)(C) of the Internal Revenue Code, is exempt from the requirements of this section if the Commissioner determines that abortion care services are excluded from the safe harbor provisions for preventive care under § 223(c)(2)(C) of the Internal Revenue Code.
Md. Code Ann., Ins. § 15-858 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–858LinkCopy Citation
(a)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide coverage for prescription drugs under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide coverage for prescription drugs under individual or group contracts that are issued or delivered in the State.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for prescription drugs through a pharmacy benefits manager is subject to the requirements of this section.
(b)
An entity subject to this section may not apply a prior authorization requirement for a prescription drug used as postexposure prophylaxis for the prevention of HIV if the prescription drug is prescribed for use in accordance with Centers for Disease Control and Prevention guidelines.
Md. Code Ann., Ins. § 15-859 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–859LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Biomarker” means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene–drug interactions for medications being considered for use or already being administered.
(ii)
“Biomarker” includes gene mutations, characteristics of genes, or protein expression.
(3)
(i)
“Biomarker testing” is the analysis of a patient’s tissue, blood, or other biospecimen for the presence of a biomarker, the results of which:
(1)
provide information that may be used in the formulation of a treatment or monitoring strategy that informs a patient’s outcome and impacts the clinical decision; and
(2)
include both information that is actionable and some information that cannot be immediately used in the formulation of a clinical decision.
(ii)
“Biomarker testing” includes single–analyte tests, multi–plex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section shall provide coverage for biomarker testing for the purpose of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition that is supported by medical and scientific evidence, including testing:
(1)
cleared or approved by the U.S. Food and Drug Administration;
(2)
required or recommended for a drug approved by the U.S. Food and Drug Administration to ensure an insured or enrollee is a good candidate for the drug treatment;
(3)
required or recommended through a warning or precaution for a drug approved by the U.S. Food and Drug Administration to identify whether an insured or enrollee will have an adverse reaction to the drug treatment or dosage;
(4)
covered under a Centers for Medicare and Medicaid Services National Coverage Determination or Medicare Administrative Contractor Local Coverage Determination; or
(5)
supported by nationally recognized clinical practice guidelines that are:
(i)
developed by independent organizations or medical professional societies using a transparent methodology and reporting structure and that have a conflict of interest policy; and
(ii)
established standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care.
(d)
An entity subject to this section shall ensure that the coverage required under subsection (c) of this section is provided in a manner that limits disruptions in care including the need for multiple biopsies or biospecimen samples.
(e)
(1)
Subject to paragraph (2) of this subsection, the coverage required under this section may be subject to the annual deductibles, copayments, or coinsurance requirements imposed by an entity subject to this section for similar coverages under the same health insurance policy or contract.
(2)
The annual deductibles, copayments, or coinsurance requirements imposed under paragraph (1) of this subsection for the coverage required under this section may not be greater than the annual deductibles, copayments, or coinsurance requirements imposed by the entity for similar coverages.
Md. Code Ann., Ins. § 15-860 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–860LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
(1)
An entity subject to this section shall provide coverage for recommended lung cancer screening or follow–up diagnostic imaging to assist in the diagnosis of lung cancer for individuals for which lung cancer screening or follow–up diagnostic imaging is recommended by the U.S. Preventative Services Task Force.
(2)
The coverage required under paragraph (1) of this subsection:
(i)
shall include diagnostic ultrasound, magnetic resonance imaging, computed tomography, and image–guided biopsy; and
(ii)
may not be subject to a prior authorization requirement.
(c)
(1)
Except as provided in paragraph (2) of this subsection, an entity subject to this section may not impose a copayment, coinsurance, or deductible requirement on coverage for lung cancer screening or follow–up diagnostic imaging that is greater than the copay, coinsurance, or deductible requirement for breast cancer screening or diagnosis.
(2)
If an insured or enrollee is covered under a high–deductible health plan, as defined in 26 U.S.C. § 223, an entity subject to this section may subject follow–up diagnostic lung imaging to the deductible requirement of the high–deductible health plan.
Md. Code Ann., Ins. § 15-861 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–861LinkCopy Citation
(a)
In this section, “special pediatric hospital” has the meaning stated in § 15–101 of the Health – General Article.
(b)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(c)
An entity subject to this section may not require prior authorization for a transfer to a special pediatric hospital.
Md. Code Ann., Ins. § 15-862 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–862LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section that covers the delivery of anesthesia for a procedure for which a licensed medical professional issues an order:
(1)
shall provide coverage for:
(i)
the delivery of anesthesia for the entire duration of the procedure; and
(ii)
medical care related to the delivery of anesthesia for the procedure that is provided immediately before and after the procedure; and
(2)
may not establish, implement, or enforce a policy, practice, or procedure that places time limitations on the delivery of anesthesia.
Md. Code Ann., Ins. § 15-863 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–863LinkCopy Citation
(a)
This section applies to:
(1)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(2)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)
An entity subject to this section shall provide coverage for calcium score testing in accordance with the most recent guidelines issued by the American College of Cardiology that expand the scope of preventive care services for the benefit of consumers.
Md. Code Ann., Ins. § 15-864 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–864LinkCopy Citation
Md. Code Ann., Ins. § 15-865 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–865LinkCopy Citation
Md. Code Ann., Ins. § 15-866 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–866LinkCopy Citation
Md. Code Ann., Ins. § 15-867 (2026)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits
§ 15–867LinkCopy Citation
Subtitle 9. Medicare Supplement Act
Md. Code Ann., Ins. § 15-901 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–901LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Applicant” means:
(1)
for an individual Medicare supplement policy or subscriber contract, the individual who seeks to contract for insurance benefits; or
(2)
for a group Medicare supplement policy or subscriber contract, the proposed certificate holder.
(c)
“Carrier” means an insurer, nonprofit health service plan, or fraternal benefit society that is authorized to issue health insurance policies under this article.
(d)
“Certificate” means a certificate that is delivered or issued for delivery in the State under a group Medicare supplement policy.
(e)
“Certificate form” means the form on which the certificate is delivered or issued for delivery in the State by the carrier.
(f)
“CMS” means the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services.
(g)
“Medicaid” means the Health Insurance for the Aged Act, Title XIX of the Social Security Amendments of 1965, as amended.
(h)
“Medicare” means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as amended.
(i)
“Medicare benefit period” means the unit of time used in the Medicare Program to measure use of services and availability of benefits under Medicare Part A.
(j)
“Medicare eligible expense” means a health care expense of the kind covered by Medicare to the extent the service for which the expense was incurred is considered reasonable under Medicare rules and regulations.
(k)
(1)
“Medicare supplement policy” or “Medigap policy” means an individual or group policy of health insurance or subscriber contract that is advertised, marketed, or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical, or surgical expenses of individuals eligible for Medicare.
(2)
“Medicare supplement policy” or “Medigap policy” does not include:
(i)
a policy that is issued pursuant to a contract under § 1876 of the federal Social Security Act, 42 U.S.C. § 1395mm; or
(ii)
a policy that is issued under a demonstration project authorized pursuant to amendments to the federal Social Security Act.
(l)
“Policy” includes:
(1)
a policy that is issued to an individual;
(2)
a certificate, as that term is used in Title 14, Subtitle 1 of this article, that is issued to an individual subscriber;
(3)
a certificate, as that term is used in Title 8, Subtitle 4 of this article, that is issued to a member of a fraternal benefit society; and
(4)
a group policy authorized to be issued under this article.
(m)
“Policy form” means the form on which the policy is delivered or issued for delivery in the State by the carrier.
Md. Code Ann., Ins. § 15-902 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–902LinkCopy Citation
This subtitle is not intended to prohibit or apply to policies, including group conversion policies, provided to Medicare eligible individuals, if the policies are not marketed or held to be Medicare supplement policies.
Md. Code Ann., Ins. § 15-903 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–903LinkCopy Citation
(a)
Notwithstanding any other provision to the contrary, this subtitle applies to:
(1)
Medicare supplement policies and subscriber contracts that are delivered or issued for delivery in the State after July 1, 1992;
(2)
certificates that are issued under group Medicare supplement policies or subscriber contracts, which certificates have been delivered or issued for delivery in the State;
(3)
individual or group Medicare supplement policies and certificates that are issued by nonprofit health service plans under Title 14, Subtitle 1 of this article;
(4)
Medicare supplement policies and certificates that are issued by fraternal benefit societies under Title 8, Subtitle 4 of this article; and
(5)
Medicare supplement group or blanket policies and certificates that are issued by insurers subject to Subtitle 3 of this title.
(b)
This subtitle does not apply to a policy of:
(1)
one or more employers or labor organizations; or
(2)
the trustees of a fund established by one or more employers or labor organizations for employees, members, former employees, or former members.
(c)
A health maintenance organization that enrolls members eligible for Medicare benefits under Title XVIII of the Social Security Act is subject to the requirements of this subtitle to the extent any of the provisions of this subtitle apply to the Medicare eligible members.
Md. Code Ann., Ins. § 15-904 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–904LinkCopy Citation
(a)
A carrier may not issue, deliver, or renew a Medicare supplement policy in the State unless the Medicare supplement policy complies with this subtitle.
(b)
(1)
Notwithstanding any other provision of this subtitle, an insurer or a nonprofit health service plan that is authorized to issue Medicare supplement policies under this article may issue Medicare supplement policies under the Medicare Select Program.
(2)
The requirements for a Medicare supplement policy issued under the Medicare Select Program shall be consistent with requirements set forth in the federal Omnibus Budget Reconciliation Act of 1990 and any subsequent relevant federal law and regulations.
(3)
The Maryland Department of Health shall determine the adequacy of the network established by an insurer or a nonprofit health service plan under the Medicare Select Program, as to the number of providers, geographic location, hours of operation, promptness of service, and range of services, in the same manner as determined for a health maintenance organization under §§ 19–705.1 and 19–705.2 of the Health – General Article.
(c)
The Commissioner may adopt regulations, in consultation with the Secretary of Health, to establish the requirements of the Medicare Select Program.
Md. Code Ann., Ins. § 15-905 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–905LinkCopy Citation
A carrier shall restore any benefit that was eliminated from a Medicare supplement policy because of the federal Medicare Catastrophic Coverage Act of 1988.
Md. Code Ann., Ins. § 15-906 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–906LinkCopy Citation
(a)
A Medicare supplement policy shall provide the minimum benefits required by federal law.
(b)
(1)
For benefits designed to cover deductibles or coinsurance amounts under Medicare, a Medicare supplement policy shall provide for an automatic change in those benefits to coincide with changes in applicable Medicare deductible and copayment provisions.
(2)
Subject to approval by the Commissioner, a carrier may reserve the right in a Medicare supplement policy to change premiums to correspond with changes in benefits under paragraph (1) of this subsection.
(c)
Payment of a benefit for a Medicare eligible expense under a Medicare supplement policy may be conditioned on the same or less restrictive payment conditions that apply to a Medicare claim, including the determination of medical necessity.
(d)
(1)
Unless otherwise expressly authorized under this article or a regulation adopted by the Commissioner under this article, coverage under a Medicare supplement policy may not be subject to any exclusion, limitation, or reduction that is inconsistent with the exclusions, limitations, or reductions under Medicare.
(2)
To the extent a benefit is available to the insured under Medicare, a Medicare supplement policy shall provide that coverage for the benefit is not duplicated.
(e)
If the insured is receiving medical assistance under Medicaid, a Medicare supplement policy shall provide for the suspension of policy benefits and premiums for a maximum of 24 months.
(f)
(1)
A Medicare supplement policy, contract, or certificate in force in the State may not provide benefits that duplicate benefits provided by Medicare.
(2)
Unless approved by the Commissioner, a Medicare supplement policy may not be offered at an introductory premium rate.
Md. Code Ann., Ins. § 15-907 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–907LinkCopy Citation
(a)
In this section, “low-dose mammography” means an x-ray examination of the breast using dedicated equipment, including an x-ray tube, filter, compression device, screens, films, and cassettes, specifically for mammography that delivers an average radiation exposure of less than one rad mid-breast with two views for each breast.
(b)
If the federal standard under § 1882(p) of the federal Social Security Act is amended to authorize the inclusion of an annual mammography screening benefit in the core group of basic benefits for Medicare supplement policies, a Medicare supplement policy shall provide for coverage for an annual screening by low-dose mammography for the presence of occult breast cancer.
Md. Code Ann., Ins. § 15-908 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–908LinkCopy Citation
The Commissioner shall approve Medicare supplement policies that include benefits in addition to the minimum benefits listed in § 15-906(a) of this subtitle if the Medicare supplement policies and benefits:
(1)
conform with the federal Omnibus Budget Reconciliation Act of 1990 and the Medicare Supplement Insurance Minimum Standards Model Act and any regulations under the Model Act adopted by the National Association of Insurance Commissioners; and
(2)
comply with the applicable provisions of this article.
Md. Code Ann., Ins. § 15-909 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–909LinkCopy Citation
(a)
This section does not extend the number of days of hospitalization offered under § 15–906(a) of this subtitle to the extent those days of hospitalization have been used under the original Medicare supplement policy.
(b)
(1)
If an application for a Medicare supplement policy or certificate is submitted during the 6–month period beginning with the first month in which an individual who is at least 65 years old first enrolls for benefits under Medicare Part B, a carrier:
(i)
may not deny or condition the issuance or effectiveness of the Medicare supplement policy or certificate or discriminate in the pricing of the Medicare supplement policy or certificate because of the health status, claims experience, receipt of health care, or medical condition of the applicant; or
(ii)
may not deny, reduce, or condition coverage or apply an increased premium rating to an applicant for a Medicare supplement policy because of the health status, claims experience, or medical condition of the applicant or the use of medical care by the applicant.
(2)
Notwithstanding paragraph (1)(ii) or (8)(iii)2 of this subsection, a carrier may include in a Medicare supplement policy a provision that complies with subsection (d) of this section.
(3)
A carrier that issues Medicare supplement policies in the State shall issue any Medicare supplement policy the carrier sells to an individual eligible for Medicare if the individual:
(i)
was enrolled in Medicare Part B while enrolled in the Maryland Medical Assistance Program;
(ii)
was not disenrolled or terminated from the Maryland Medical Assistance Program until at least 6 months following the effective date of enrollment in Medicare Part B;
(iii)
applies for the Medicare supplement policy during the 63–day period following the later of notice of termination or disenrollment or the date of termination from the Maryland Medical Assistance Program; and
(iv)
submits evidence of the date of termination or disenrollment from the Maryland Medical Assistance Program with the application for a Medicare supplement policy.
(4)
A carrier that issues Medicare supplement policies in the State shall issue any Medicare supplement policy currently open to new enrollees to an individual eligible for Medicare if the individual:
(i)
became eligible for Medicare before January 1, 2020;
(ii)
qualifies under any federal special enrollment period guaranteed issue right, including for plans issued on or after January 1, 2020;
(iii)
applies for the Medicare supplement policy during the 63–day period following the qualifying event for the federal special enrollment period guaranteed issue right; and
(iv)
submits evidence of the date of the qualifying event for the federal special enrollment period guaranteed issue right with the application for a Medicare supplement policy.
(5)
(i)
A carrier shall make available Medicare supplement policy plans A and D to an individual who is under the age of 65 years but is eligible for Medicare due to a disability, if an application for a Medicare supplement policy or certificate is submitted:
(1)
during the 6–month period following the applicant’s enrollment in Part B of Medicare; or
(2)
if the applicant is notified by Medicare of the applicant’s retroactive enrollment in Medicare, during the 6–month period following notification of enrollment in Medicare.
(ii)
For a Medicare supplement policy plan A or D required to be made available under subparagraph (i) of this paragraph, a carrier:
(1)
may not deny or condition the issuance or effectiveness of a Medicare supplement policy plan A or D because of the health status, claims experience, receipt of health care, or medical condition of the applicant; or
(2)
may not deny, reduce, or condition coverage to the applicant for a Medicare supplement policy plan A or D because of the health status, claims experience, or medical condition of the applicant or the use of medical care by the applicant.
(iii)
For a Medicare supplement policy plan A required to be made available under subparagraph (i) of this paragraph, a carrier may not charge individuals who are under the age of 65 years, but are eligible for Medicare due to a disability, a rate higher than the average of the premiums paid by all policyholders age 65 and older in the State who are covered under that plan A policy form.
(6)
A carrier may elect to offer Medicare supplement policy plans to individuals who are under the age of 65 years, but eligible for Medicare due to a disability, in addition to the Medicare supplement policy plans A and D that are required to be offered under paragraph (5)(i) of this subsection.
(7)
Paragraph (5) of this subsection may not be construed to require a carrier to offer a Medicare supplement policy plan to individuals who are under the age of 65 years, but are eligible for Medicare due to a disability, if the plan is not offered to individuals who are eligible for Medicare due to age.
(8)
(i)
This paragraph applies only on and after July 1, 2023.
(ii)
During the 30 days following the birthday of an individual enrolled in a Medicare supplement policy, a carrier shall make available to the individual different Medicare supplement policies with benefits that are equal to or less than the benefits of the individual’s existing coverage.
(iii)
(1)
For purposes of this paragraph, a Medicare supplement policy has equal or lesser benefits unless:
(A)
it contains one or more significant benefits not included in the Medicare supplement policy being replaced; or
(B)
it contains the same significant benefits included in the Medicare supplement policy being replaced but it reduces the cost–sharing responsibilities of the enrollee for the benefits.
(2)
The Commissioner shall adopt regulations establishing a matrix for identifying which Medicare supplement policies have equal or lesser benefits.
(iv)
For a Medicare supplement policy required to be made available under subparagraph (ii) of this paragraph, a carrier may not:
(1)
deny or condition the issuance or effectiveness of a Medicare supplement policy, or discriminate in the pricing of the policy, because of the health status, claims experience, or medical condition of the individual or the receipt of health care by the individual; or
(2)
deny, reduce, or condition coverage to the individual for a Medicare supplement policy because of the health status, claims experience, or medical condition of the individual or the use of medical care by the individual.
(v)
A carrier that offers Medicare supplement policies shall notify an insured of the insured’s rights under this paragraph at least 30 days, but not more than 60 days, before the insured’s birthday.
(c)
Regardless of the applicant’s age, each Medicare supplement policy or applicable certificate that a carrier currently has available shall be made available to each applicant who qualifies under subsection (b) of this section.
(d)
(1)
Notwithstanding any other provision of law, a Medicare supplement policy or certificate may not exclude or limit benefits for losses incurred more than 6 months after the effective date of coverage because the losses involved a preexisting condition.
(2)
A Medicare supplement policy or certificate may not define a preexisting condition more restrictively than a condition for which a physician gave medical advice or recommended or gave treatment within 6 months before the effective date of coverage.
(e)
If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate, the succeeding carrier shall waive the time periods applicable to preexisting conditions, waiting periods, elimination periods, and probationary periods in the new Medicare supplement policy or certificate for similar benefits to the extent the time was spent under the original Medicare supplement policy or certificate.
(f)
A carrier may not cancel or nonrenew a Medicare supplement policy or certificate for any reason other than for nonpayment of premium or material misrepresentation.
(g)
(1)
(i)
If the group policyholder terminates a group Medicare supplement policy without replacing the group Medicare supplement policy under paragraph (3) of this subsection, the carrier shall offer each certificate holder an individual Medicare supplement policy.
(ii)
The carrier shall offer the certificate holder at least the following:
(1)
an individual Medicare supplement policy that provides for continuation of the benefits contained in the group policy; or
(2)
an individual Medicare supplement policy that provides only the benefits that are required under § 15–906(a) of this subtitle.
(2)
If membership in a group is terminated, the carrier:
(i)
shall offer the certificate holder the conversion options under paragraph (1) of this subsection; or
(ii)
at the option of the group policyholder, shall offer the certificate holder a continuation of coverage under the group Medicare supplement policy.
(3)
(i)
If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the succeeding carrier shall offer coverage to each individual who was covered under the old group Medicare supplement policy on its date of termination.
(ii)
Under the new group Medicare supplement policy, coverage may not be excluded for a preexisting condition that would have been covered under the group Medicare supplement policy being replaced.
Md. Code Ann., Ins. § 15-910 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–910LinkCopy Citation
(a)
Each Medicare supplement policy or certificate shall have prominently printed on the first page of the policy or certificate or attached to it, a notice that states that the applicant may:
(1)
return the Medicare supplement policy or certificate within 30 days after its delivery; and
(2)
receive a refund of the premium if after examination of the Medicare supplement policy or certificate, the applicant is not satisfied for any reason.
(b)
The carrier shall pay a refund made under this section directly to the applicant in a timely manner.
Md. Code Ann., Ins. § 15-911 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–911LinkCopy Citation
(a)
In this section, “loss ratio” means the ratio of losses incurred to premiums earned on policies that are issued, delivered, or renewed in the State.
(b)
Medicare supplement policies shall return aggregate benefits that are reasonable in relation to the premium charged.
(c)
(1)
For purposes of administering this subtitle and §§ 12-203 through 12-205 of this article, the Commissioner shall adopt reasonable regulations to establish minimum standards for loss ratios of Medicare supplement policies.
(2)
The minimum standards for loss ratios shall be based on incurred claims experience and earned premiums in accordance with accepted actuarial principles and practices and the principles and standards of the National Association of Insurance Commissioners.
(d)
The minimum acceptable loss ratios for Medicare supplement policies are:
(1)
for group Medicare supplement policies, at least 75% of the aggregate amount of premiums earned; and
(2)
for individual Medicare supplement policies or subscriber contracts that are issued or renewed on a policy anniversary after July 1, 1991, at least 65% of the aggregate amount of premiums earned.
(e)
(1)
To demonstrate compliance with the applicable minimum loss ratio standards established in the State for Medicare supplement policies, each carrier that provides Medicare supplement policies or certificates in the State shall file annually with the Commissioner the carrier’s rates, rating schedule, and supporting documentation.
(2)
Each filing of rates and rating schedules shall demonstrate that the actual and expected losses in relation to premiums comply with the requirements of this subtitle.
(f)
The Commissioner may require a carrier to adjust rates or give credits or refunds to policyholders of Medicare supplement policies that in practice do not meet the minimum loss ratio standards required under this section.
Md. Code Ann., Ins. § 15-912 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–912LinkCopy Citation
(a)
The Commissioner shall adopt reasonable regulations to establish specific standards for policy provisions of Medicare supplement policies and certificates.
(b)
(1)
The standards adopted by the Commissioner are in addition to and shall be in accordance with applicable laws of the State, including this title and Title 14, Subtitle 1 of this article.
(2)
No requirement of this article that relates to minimum required policy benefits, other than the minimum standards contained in this subtitle, shall apply to Medicare supplement policies and certificates.
(c)
The standards may cover, but are not limited to:
(1)
terms of renewability;
(2)
initial and subsequent conditions of eligibility;
(3)
nonduplication of coverage;
(4)
probationary periods;
(5)
benefit limitations, exceptions, and reductions;
(6)
elimination periods;
(7)
replacement requirements;
(8)
recurrent conditions;
(9)
definitions of terms; and
(10)
any other provisions required under federal Medicare law or CMS regulations.
Md. Code Ann., Ins. § 15-913 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–913LinkCopy Citation
The Commissioner shall adopt reasonable regulations that specify prohibited policy provisions, not otherwise specifically authorized by statute, that in the opinion of the Commissioner are unjust, unfair, or unfairly discriminatory to any individual insured or proposed to be insured under a Medicare supplement policy or certificate.
Md. Code Ann., Ins. § 15-914 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–914LinkCopy Citation
The Commissioner shall adopt reasonable regulations to establish minimum standards for benefits, claim payments, marketing practices, and compensation arrangements and reporting practices for Medicare supplement policies and certificates.
Md. Code Ann., Ins. § 15-915 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–915LinkCopy Citation
(a)
The Commissioner shall adopt reasonable regulations as necessary to conform Medicare supplement policies and certificates to the requirements of federal law and regulations.
(b)
The regulations may include, but are not limited to, provisions that:
(1)
require rate adjustments, credits, or refunds if the Medicare supplement policies or certificates do not meet loss ratio requirements;
(2)
establish a uniform methodology for calculating and reporting loss ratios;
(3)
ensure public access to policies, premiums, and loss ratio information of carriers of Medicare supplement insurance;
(4)
establish a process for approving or disapproving policy forms and certificate forms; and
(5)
establish a policy for holding public hearings before approval of premium increases and a process for approving or disapproving proposed schedules of premium changes.
Md. Code Ann., Ins. § 15-916 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–916LinkCopy Citation
(a)
The Commissioner shall prepare in clear, plain English the text of a Medicare supplement buyer’s guide that carriers must provide to prospective buyers of Medicare supplement policies under this section.
(b)
The buyer’s guide shall:
(1)
contain an outline of Medicare coverage; and
(2)
include advice and other information about purchasing Medicare supplement policies, including a reference to the right of the buyer to cancel a Medicare supplement policy during the first 30 days after it is delivered, as provided in § 15-910 of this subtitle.
(c)
The Commissioner shall submit the text of the buyer’s guide for publication in the Maryland Register and at the same time send a copy of the text to the Department of Aging.
(d)
The carrier or insurance producer of the carrier shall deliver to the prospective buyer a Medicare supplement buyer’s guide that is printed in at least 12-point type:
(1)
before accepting an application;
(2)
when an existing policy is converted to a Medicare supplement policy; and
(3)
at any other time required by the Commissioner by regulation.
(e)
A carrier shall provide:
(1)
a copy of the Medicare supplement buyer’s guide to an individual covered under a group health insurance policy when the individual becomes eligible for Medicare by reason of age; and
(2)
any information required under § 15-919 of this subtitle that is applicable to the continuing coverage under the group health insurance policy of the individual eligible for Medicare.
(f)
(1)
The text of the Medicare supplement buyer’s guide shall be as the Commissioner submits for publication under subsection (c) of this section.
(2)
The form of the Medicare supplement buyer’s guide shall be as required by the Commissioner by regulation.
Md. Code Ann., Ins. § 15-917 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–917LinkCopy Citation
(a)
In order to provide for full and fair disclosure in the sale of Medicare supplement policies, a Medicare supplement policy or certificate may not be delivered in the State unless an outline of coverage is provided to the applicant at the time the application is delivered.
(b)
(1)
In this subsection, “format” means style, arrangements, and overall appearance, including the size, color, and prominence of type and arrangement of text and captions.
(2)
The Commissioner shall prescribe the format and content of the outline of coverage required by this section.
(3)
The outline of coverage shall include:
(i)
a description of the principal benefits and coverage provided in the Medicare supplement policy;
(ii)
a statement of the exceptions, reductions, and limitations contained in the Medicare supplement policy;
(iii)
a statement of the renewal provisions, including any reservation by the carrier of a right to change premiums;
(iv)
disclosure of the existence of any automatic renewal premium increases based on the policyholder’s age; and
(v)
a statement that the outline of coverage is a summary of the Medicare supplement policy that is issued or applied for and that the Medicare supplement policy should be consulted to determine governing contractual provisions.
Md. Code Ann., Ins. § 15-918 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–918LinkCopy Citation
(a)
The Commissioner may prescribe by regulation a standard form and the contents of an informational brochure for individuals eligible for Medicare by reason of age, which is intended to improve the buyer’s ability to choose the most appropriate coverage and to improve the buyer’s understanding of Medicare.
(b)
Except for direct response insurance policies, the Commissioner may require by regulation that the informational brochure be provided to each prospective insured eligible for Medicare at the time of delivery of the outline of coverage.
(c)
For direct response insurance policies, the Commissioner may require by regulation that the informational brochure be provided on request to a prospective insured eligible for Medicare by reason of age, but not later than the time of delivery of the policy.
Md. Code Ann., Ins. § 15-919 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–919LinkCopy Citation
(a)
(1)
Under any circumstance stated in this section, a carrier or insurance producer of a carrier shall give to a prospective buyer eligible for Medicare by reason of age a written statement as required, for each circumstance, by this section.
(2)
The written statement shall be given before the carrier or insurance producer accepts an application.
(b)
If the proposed policy excludes or limits benefits for preexisting conditions, a statement shall be given that describes in plain language the limitations or exclusions.
(c)
If the proposed policy provides coverage for care in a Medicare–approved skilled nursing facility, but the policy does not provide coverage for care in other nursing home facilities or for custodial or rest home care, a statement shall be given that describes clearly those expenses that the policy does not cover.
(d)
(1)
If the proposed policy does not comply with the requirements of §§ 15–904, 15–906, 15–907, and 15–908 of this subtitle for a Medicare supplement policy, a statement printed in 12–point type shall be given that:
“This policy (or certificate) is not a Medicare supplement policy (or certificate). It is not designed to fill the ‘gaps’ of Medicare. If you are eligible for Medicare, review the Medicare supplement buyer’s guide available from the company”.
(2)
The statement required by paragraph (1) of this subsection shall be printed on or attached to the first page of:
(i)
the policy form or certificate; or
(ii)
an outline of coverage delivered to the individual covered under the policy or certificate.
(3)
A carrier or insurance producer of a carrier need not provide the statement required under paragraph (1) of this subsection for:
(i)
a policy or certificate that is issued in accordance with a contract under § 1876 of the federal Social Security Act, 42 U.S.C. § 1395mm;
(ii)
a disability income policy; or
(iii)
a policy or contract of one or more employers or labor organizations or the trustees of a fund established by one or more employers or labor organizations or a combination of employers or labor organizations, for employees, former employees, a combination of employees or former employees, members, former members, or a combination of members or former members of the labor organization.
(4)
Notwithstanding paragraph (1) of this subsection, the Commissioner shall adopt regulations necessary to conform this subsection to the requirements of applicable federal law.
(e)
If the proposed policy provides accident–only benefits, a statement printed in 12–point type shall be given that contains the language in subsection (d) of this section and the following:
“This is an accident only policy. It does not pay benefits for loss due to sickness”.
Md. Code Ann., Ins. § 15-920 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–920LinkCopy Citation
The Commissioner may adopt regulations for captions or notice requirements, determined to be in the public interest and designed to inform prospective insureds that particular insurance coverages are not Medicare supplement coverages, for all health insurance policies sold to individuals eligible for Medicare, other than Medicare supplement policies or disability income policies.
Md. Code Ann., Ins. § 15-921 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–921LinkCopy Citation
The Commissioner may adopt reasonable regulations to govern the full and fair disclosure of the information in connection with the replacement of health insurance policies, subscriber contracts, or certificates by individuals eligible for Medicare.
Md. Code Ann., Ins. § 15-922 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–922LinkCopy Citation
(a)
(1)
In this section, “compensation” means any pecuniary or nonpecuniary remuneration related to the sale or renewal of a Medicare supplement policy or certificate.
(2)
“Compensation” includes bonuses, gifts, and finders’ fees.
(3)
“Compensation” does not include noncash prizes or awards.
(b)
A carrier or other entity may provide a commission or other compensation to an insurance producer or other representative for the sale of a Medicare supplement policy or certificate only if the first year commission or other first year compensation is not more than 200% of the commission or other compensation paid for selling or servicing the Medicare supplement policy or certificate in the second year or period.
(c)
A carrier or other entity must provide the same commission or other compensation in subsequent renewal years as the commission or other compensation provided in the second year or period and for no fewer than 5 renewal years.
(d)
If an existing Medicare supplement policy or certificate is replaced, the carrier or other entity may not provide to its insurance producers or other producers, and an insurance producer or other producer may not receive, compensation greater than the renewal compensation payable by the succeeding carrier on renewal Medicare supplement policies or certificates.
Md. Code Ann., Ins. § 15-922.1 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–922.1LinkCopy Citation
(a)
This section applies to a Medicare supplement policy issued:
(1)
under § 15–909(b)(6) of this subtitle; or
(2)
to an individual at least 65 years old.
(b)
A carrier shall pay the same commission rates to an insurance producer for the sale of a Medicare supplement policy without regard to whether the policy is sold during an open enrollment period, as an underwritten policy, or under § 15–909(b)(6) of this subtitle.
Md. Code Ann., Ins. § 15-923 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–923LinkCopy Citation
Each carrier that offers a Medicare supplement policy in the State shall provide a copy of any Medicare supplement advertisement that the carrier intends to use in the State whether through a written, radio, or television medium to the Commissioner for review at least 5 business days before the carrier uses the advertisement.
Md. Code Ann., Ins. § 15-924 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–924LinkCopy Citation
(a)
Solicitation of the sale of a health insurance policy proposed to be issued to an individual eligible for Medicare may be made only in accordance with this section and § 15-925 of this subtitle.
(b)
(1)
When soliciting the sale of a health insurance policy to an individual eligible for Medicare, a carrier or insurance producer shall ask the individual whether the individual:
(i)
is already covered by an existing Medicare supplement policy; and
(ii)
is entitled to Medicaid benefits.
(2)
The carrier or insurance producer shall obtain a written statement from the individual that verifies the individual’s information provided under paragraph (1) of this subsection.
(c)
When soliciting or advertising the sale of a health insurance policy to an individual eligible for Medicare, a carrier or insurance producer may not:
(1)
represent or imply that the carrier or insurance producer represents, works for, or is compensated by a federal, State, or local government agency;
(2)
falsely represent or imply that the carrier or insurance producer is offering insurance to supplement Medicare that is approved or recommended by a federal, State, or local government agency;
(3)
use terms such as “Medicare consultant”, “Medicare advisor”, “Medicare bureau”, or “disability insurance consultant” when describing the carrier or insurance producer in a letter, envelope, reply card, or any other writing or advertisement or in any oral representation; or
(4)
knowingly make a misrepresentation or incomplete or fraudulent comparison by commission or omission of a policy or carrier to induce or attempt to induce the individual to:
(i)
purchase, amend, lapse, surrender, forfeit, change, duplicate, or not renew coverage already in force;
(ii)
replace a policy that is only technically at variance with the policy being offered by the carrier or insurance producer; or
(iii)
take out a policy with another carrier.
Md. Code Ann., Ins. § 15-925 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–925LinkCopy Citation
(a)
When soliciting the sale of a health insurance policy, a carrier or insurance producer may not knowingly offer a Medicare supplement policy to an individual not eligible for Medicare.
(b)
A carrier or insurance producer may only sell or offer to sell a Medicare supplement policy to an individual eligible for Medicaid benefits in accordance with the provisions of 42 U.S.C. § 1395ss and this subtitle.
(c)
A carrier or insurance producer may not negligently or knowingly sell or offer to sell to an individual a Medicare supplement policy that duplicates to any extent an existing Medicare supplement policy that covers that individual.
(d)
A carrier or insurance producer may not use the terms “Medicare supplement”, “Medigap”, or other words of similar meaning in advertising or otherwise in soliciting the sale of a health insurance policy or other policy, unless the policy conforms to §§ 15-904, 15-906, 15-907, and 15-908 of this subtitle.
Md. Code Ann., Ins. § 15-926 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–926LinkCopy Citation
(a)
Each carrier that issues Medicare supplement policies shall provide to CMS any data, statistics, or other information that CMS requests about the carrier’s Medicare supplement policies.
(b)
On request from CMS, the Commissioner may provide to CMS any information about Medicare supplement policies that are issued in the State.
Md. Code Ann., Ins. § 15-927 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–927LinkCopy Citation
In addition to any other applicable penalties for violations of this article, the Commissioner may require a carrier that violates this subtitle or a regulation adopted under this subtitle to cease marketing any Medicare supplement policy or certificate in the State that is related directly or indirectly to the violation, or may require the carrier to take actions necessary to comply with this subtitle, or both.
Md. Code Ann., Ins. § 15-928 (2026)
Title 15. Health Insurance
Subtitle 9. Medicare Supplement Act
§ 15–928LinkCopy Citation
This subtitle is the Medicare Supplement Act.
Subtitle 10. Claims and Utilization Review
Md. Code Ann., Ins. § 15-1001 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1001LinkCopy Citation
(a)
This section applies to entities that propose to issue or deliver individual, group, or blanket health insurance policies or contracts in the State or to administer health benefit programs that provide for the coverage of health care services and the utilization review of those services, including:
(1)
an authorized insurer that provides health insurance in the State;
(2)
a nonprofit health service plan;
(3)
a health maintenance organization;
(4)
a dental plan organization; or
(5)
except for a managed care organization as defined in Title 15, Subtitle 1 of the Health - General Article, any other person that provides health benefit plans subject to regulation by the State.
(b)
(1)
Subject to paragraph (2) of this subsection, each entity subject to this section shall:
(i)
(1)
have a certificate issued under Subtitle 10B of this title; or
(2)
contract with a private review agent that has a certificate issued under Subtitle 10B of this title; and
(ii)
when conducting utilization review for mental health and substance use benefits, ensure that the criteria and standards used are in compliance with the federal Mental Health Parity and Addiction Equity Act.
(2)
For hospital services, each entity subject to this section may contract with or delegate utilization review to a hospital utilization review program approved under § 19–319(d) of the Health – General Article.
(c)
Notwithstanding any other provision of this article, if the medical necessity of providing a covered benefit is disputed, an entity subject to this section that does not meet the requirements of subsection (b) of this section shall pay any person entitled to reimbursement under the policy or contract in accordance with the determination of medical necessity by:
(1)
the treating provider; or
(2)
when hospital services are provided, the hospital utilization review program approved under § 19-319(d) of the Health - General Article.
(d)
An entity subject to this section may not:
(1)
act as a private review agent without holding a certificate issued under Subtitle 10B of this title; or
(2)
use a private review agent that does not hold a certificate issued under Subtitle 10B of this title.
(e)
An entity that violates any provision of this section is subject to the penalties provided under § 15-10B-12 of this title.
Md. Code Ann., Ins. § 15-1002 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1002LinkCopy Citation
To provide a standard system of payment for medical services, each claim form for use under an individual or group health insurance policy that is issued or delivered in the State shall conform to a form or regulations that the Commissioner adopts.
Md. Code Ann., Ins. § 15-1003 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1003LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Health care practitioner” means a person that is licensed or certified under the Health Occupations Article and reimbursed by a third party payor.
(ii)
“Health care practitioner” does not include a physician or other person licensed or certified under this article when the physician or other person is rendering care to a member or subscriber of a health maintenance organization and is compensated by the health maintenance organization for that care on a salaried or capitated basis.
(3)
“Hospital” has the meaning stated in § 19-301 of the Health - General Article.
(b)
The Commissioner shall adopt by regulation as the uniform claims form for reimbursement of hospital services in the State the uniform claims form adopted by the National Uniform Billing Committee and approved by the Centers for Medicare and Medicaid Services for Hospital Payments under Title XVIII of the Social Security Act.
(c)
The Commissioner shall adopt by regulation a uniform claims form for reimbursement of health care practitioners’ services.
(d)
(1)
The Commissioner shall adopt by regulation:
(i)
a definition of a clean claim, including:
(1)
the essential data elements that must be completed on the uniform claims form; and
(2)
uniform standards for attachments to the uniform claims form;
(ii)
permissible categories of disputed claims for which additional information may be requested under §§ 15-1004(c) and 15-1005(c) of this subtitle; and
(iii)
standards for determining when a claim is considered received for reimbursement.
(2)
In adopting the regulations required under paragraph (1)(i) of this subsection, the Commissioner shall consider:
(i)
standards for attachments required by the federal Centers for Medicare and Medicaid Services for the Medicare Program;
(ii)
standards used by insurance carriers, nonprofit health service plans, and health maintenance organizations in the State; and
(iii)
federal regulations adopted under the Health Insurance Portability and Accountability Act.
Md. Code Ann., Ins. § 15-1004 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1004LinkCopy Citation
(a)
For services rendered by a person entitled to reimbursement under § 15–701(a) of this title or by a hospital, as defined in § 19–301 of the Health – General Article, an insurer, nonprofit health service plan, or health maintenance organization:
(1)
shall accept the uniform claims form and any attachments approved or adopted by the Commissioner under § 15–1003 of this subtitle:
(i)
as a properly filed claim with all necessary documentation; and
(ii)
as the sole instrument for reimbursement; and
(2)
may not impose as a condition of reimbursement a requirement to:
(i)
modify the uniform claims form or its content; or
(ii)
submit additional claims forms.
(b)
(1)
A uniform claims form submitted under this section shall be completed properly and may be submitted by electronic transfer.
(2)
If the health care practitioner rendering the service is a certified registered nurse anesthetist or certified nurse midwife, the uniform claims form shall include identification modifiers for the certified registered nurse anesthetist or certified nurse midwife that indicate whether the service is provided with or without medical direction by a physician.
(c)
In accordance with §§ 15–1003(d)(1)(ii) and 15–1005(c) of this subtitle, if the legitimacy or appropriateness of a health care service is disputed, an insurer, nonprofit health service plan, or health maintenance organization may request additional medical information that describes and summarizes the diagnosis, treatment, and services rendered to the insured.
(d)
(1)
Insurers, nonprofit health service plans, and health maintenance organizations shall provide and update, as appropriate, all contracting providers and any other provider on request, with a manual or other document that sets forth the claims filing procedures, including:
(i)
the address where the claims should be sent for processing;
(ii)
the telephone number at which providers’ questions and concerns regarding claims may be addressed;
(iii)
the name, address, and telephone number of any entity to which the insurer, nonprofit health service plan, or health maintenance organization has delegated the claims payment function, if applicable; and
(iv)
the address and telephone number of any separate claims processing center for specific types of applicable services.
(2)
If an insurer, nonprofit health service plan, or health maintenance organization has delegated its claims processing function to a third party, the delegation agreement:
(i)
shall require the claims processing entity to comply with the requirements of this subtitle; and
(ii)
may not be construed to limit the responsibility of the insurer, nonprofit health service plan, or health maintenance organization to comply with the requirements of this subtitle.
(e)
(1)
If necessary to determine eligibility for benefits or to determine coverage, an insurer, nonprofit health service plan, or health maintenance organization may obtain additional information from its insured, member, or subscriber, the employer of the insured, member or subscriber, or any other nonprovider third party.
(2)
If obtaining additional information results in a delay in paying a claim, the insurer, nonprofit health service plan, or health maintenance organization shall pay interest in accordance with the provisions of § 15–1005(g) of this subtitle.
(f)
The Commissioner may impose a penalty not exceeding $5,000 on an insurer, nonprofit health service plan, or health maintenance organization that violates this section.
Md. Code Ann., Ins. § 15-1005 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1005LinkCopy Citation
(a)
In this section, “clean claim” means a claim for reimbursement, as defined in regulations adopted by the Commissioner under § 15–1003 of this subtitle.
(b)
To the extent consistent with the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq., this section applies to an insurer, nonprofit health service plan, or health maintenance organization that acts as a third party administrator.
(c)
Except as provided in § 15–1315 of this title and subsection (i) of this section, within 30 days after receipt of a claim for reimbursement from a person entitled to reimbursement under § 15–701(a) of this title or from a hospital or related institution, as those terms are defined in § 19–301 of the Health – General Article, an insurer, nonprofit health service plan, or health maintenance organization shall:
(1)
mail or otherwise transmit payment for the claim in accordance with this section; or
(2)
send a notice of receipt and status of the claim that states:
(i)
that the insurer, nonprofit health service plan, or health maintenance organization refuses to reimburse all or part of the claim and the reason for the refusal;
(ii)
that, in accordance with § 15–1003(d)(1)(ii) of this subtitle, the legitimacy of the claim or the appropriate amount of reimbursement is in dispute and additional information is necessary to determine if all or part of the claim will be reimbursed and what specific additional information is necessary; or
(iii)
that the claim is not clean and the specific additional information necessary for the claim to be considered a clean claim.
(d)
(1)
(i)
In this subsection, “credit card” means a credit, debit, prepaid, or stored–value card used to make a payment through a private card network.
(ii)
“Credit card” includes a method of payment to a provider where no physical card is presented.
(2)
An insurer, a nonprofit health service plan, or a health maintenance organization may pay a claim under subsection (c) of this section, or a portion of a claim under subsection (f) of this section, using a credit card or an electronic funds transfer payment method that imposes on the provider a fee or similar charge to process the payment if:
(i)
the insurer, nonprofit health service plan, or health maintenance organization notifies the provider in advance of the payment that:
(1)
a fee or similar charge associated with the use of the credit card or electronic funds transfer payment method will apply; and
(2)
the provider will need to consult the provider’s merchant processor or financial institution for the specific rates;
(ii)
the insurer, nonprofit health service plan, or health maintenance organization offers the provider an alternative payment method that does not impose a fee or similar charge on the provider; and
(iii)
the provider or the provider’s designee elects to accept payment of the claim or a portion of the claim using the credit card or electronic funds transfer payment method.
(3)
If a provider participates on a provider panel of an insurer, a nonprofit health service plan, or a health maintenance organization, the acceptance by the provider or the provider’s designee of a payment method offered under paragraph (2)(ii) of this subsection or elected under paragraph (2)(iii) of this subsection shall apply to all claims paid for by the insurer, nonprofit health service plan, or health maintenance organization unless otherwise notified by the provider or the provider’s designee.
(e)
(1)
An insurer, nonprofit health service plan, or health maintenance organization shall permit a provider a minimum of 180 days from the date a covered service is rendered to submit a claim for reimbursement for the service.
(2)
If an insurer, nonprofit health service plan, or health maintenance organization wholly or partially denies a claim for reimbursement, the insurer, nonprofit health service plan, or health maintenance organization shall permit a provider a minimum of 90 working days after the date of denial of the claim to appeal the denial.
(3)
If an insurer, nonprofit health service plan, or health maintenance organization erroneously denies a provider’s claim for reimbursement submitted within the time period specified in paragraph (1) of this subsection because of a claims processing error, and the provider notifies the insurer, nonprofit health service plan, or health maintenance organization of the potential error within 1 year of the claim denial, the insurer, nonprofit health service plan, or health maintenance organization, on discovery of the error, shall reprocess the provider’s claim without the necessity for the provider to resubmit the claim, and without regard to timely submission deadlines.
(f)
(1)
If an insurer, nonprofit health service plan, or health maintenance organization provides notice under subsection (c)(2)(i) of this section, the insurer, nonprofit health service plan, or health maintenance organization shall mail or otherwise transmit payment for any undisputed portion of the claim within 30 days of receipt of the claim, in accordance with this section.
(2)
If an insurer, nonprofit health service plan, or health maintenance organization provides notice under subsection (c)(2)(ii) of this section, the insurer, nonprofit health service plan, or health maintenance organization shall:
(i)
mail or otherwise transmit payment for any undisputed portion of the claim in accordance with this section; and
(ii)
comply with subsection (c)(1) or (2)(i) of this section within 30 days after receipt of the requested additional information.
(3)
If an insurer, nonprofit health service plan, or health maintenance organization provides notice under subsection (c)(2)(iii) of this section, the insurer, nonprofit health service plan, or health maintenance organization shall comply with subsection (c)(1) or (2)(i) of this section within 30 days after receipt of the requested additional information.
(g)
(1)
If an insurer, nonprofit health service plan, or health maintenance organization fails to pay a clean claim for reimbursement or otherwise violates any provision of this section, the insurer, nonprofit health service plan, or health maintenance organization shall pay interest on the amount of the claim that remains unpaid 30 days after receipt of the initial clean claim for reimbursement at the monthly rate of:
(ii)
2% from the 61st day through the 120th day; and
(2)
The interest paid under this subsection shall be included in any late reimbursement without the necessity for the person that filed the original claim to make an additional claim for that interest.
(h)
An insurer, nonprofit health service plan, or health maintenance organization that violates a provision of this section is subject to:
(1)
a fine not exceeding $500 for each violation that is arbitrary and capricious, based on all available information; and
(2)
the penalties prescribed under § 4–113(d) of this article for violations committed with a frequency that indicates a general business practice.
(i)
(1)
An insurer, a nonprofit health service plan, or a health maintenance organization may suspend review of a claim for reimbursement for a preauthorized or approved health care service if the insurer, nonprofit health service plan, or health maintenance organization sends written notice within 30 days after receipt of the claim that informs the person filing the claim, that:
(i)
review of the claim is suspended during the second or third month of a grace period under 45 C.F.R. § 156.270(d); and
(ii)
on receipt of the payment of premium, the insurer, nonprofit health service plan, or health maintenance organization is required to comply with paragraph (2) of this subsection.
(2)
Within 30 days after receipt of the payment of premium, an insurer, a nonprofit health service plan, or a health maintenance organization shall comply with subsection (c)(1) or (2) of this section.
Md. Code Ann., Ins. § 15-1006 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1006LinkCopy Citation
(a)
On written request of the claimant, an insurer that denies a claim made on an individual health insurance policy shall give written notice to the claimant that states fully the reason for the denial.
(b)
The reason given by an insurer for denial of a claim shall not act as an estoppel or limit the insurer from offering an additional reason for the denial.
(c)
The notice given by an insurer under this section is subject to 45 C.F.R. § 164.522(b).
Md. Code Ann., Ins. § 15-1007 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1007LinkCopy Citation
(a)
This section applies to insurers and nonprofit health service plans that propose to issue or deliver individual, group, or blanket health insurance policies or contracts or to administer health benefit programs that provide hospital, medical, or surgical benefits on an expense–incurred basis.
(b)
Each entity subject to this section shall provide to an insured individual who has filed a claim described in subsection (c) of this section an annual summary explanation of benefits that covers the preceding 12–month period.
(c)
The summary explanation of benefits required under subsection (b) of this section shall provide a summary of:
(1)
all claims filed by health care providers for services rendered to the insured individual or covered dependent of the insured individual during an inpatient hospitalization or an outpatient surgical procedure;
(2)
the amount paid by the entity for each claim filed; and
(3)
the balance owed by the insured individual for each claim filed.
(d)
The explanation of benefits required under this section is subject to 45 C.F.R. § 164.522(b).
Md. Code Ann., Ins. § 15-1008 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1008LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization;
(v)
a managed care organization, as defined in § 15–101 of the Health – General Article; or
(vi)
any other person that provides health benefit plans subject to regulation by the State.
(3)
“Code” means:
(i)
the applicable current procedural terminology (CPT) code, as adopted by the American Medical Association;
(ii)
if for a dental service, the applicable code adopted by the American Dental Association; or
(iii)
another applicable code under an appropriate uniform coding scheme used by a carrier in accordance with this section.
(4)
“Coding guidelines” means those standards or procedures used or applied by a payor to determine the most accurate and appropriate code or codes for payment by the payor for a service or services.
(5)
“Health care provider” means a person or entity licensed, certified or otherwise authorized under the Health Occupations Article or the Health – General Article to provide health care services.
(6)
“Reimbursement” means payments made to a health care provider by a carrier on either a fee–for–service, capitated, or premium basis.
(b)
This section does not apply to an adjustment to reimbursement:
(1)
made as part of an annual contracted reconciliation of a risk sharing arrangement under an administrative service provider contract; or
(2)
made as part of a two–sided incentive arrangement that complies with § 15–113 of this title.
(c)
(1)
If a carrier retroactively denies reimbursement to a health care provider, the carrier:
(i)
may only retroactively deny reimbursement for services subject to coordination of benefits with another carrier, the Maryland Medical Assistance Program, or the Medicare Program during the 18–month period after the date that the carrier paid the health care provider; and
(ii)
except as provided in item (i) of this paragraph, may only retroactively deny reimbursement during the 6–month period after the date that the carrier paid the health care provider.
(2)
(i)
A carrier that retroactively denies reimbursement to a health care provider under paragraph (1) of this subsection shall provide the health care provider with a written statement specifying the basis for the retroactive denial.
(ii)
If the retroactive denial of reimbursement results from coordination of benefits by a carrier that is not a managed care organization, the written statement shall provide the name and address of the entity acknowledging responsibility for payment of the denied claim.
(d)
Except as provided in subsection (e) of this section, a carrier that does not comply with the provisions of subsection (c) of this section may not retroactively deny reimbursement or attempt in any manner to retroactively collect reimbursement already paid to a health care provider.
(e)
(1)
The provisions of subsection (c)(1) of this section do not apply if a carrier retroactively denies reimbursement to a health care provider because:
(i)
the information submitted to the carrier was fraudulent;
(ii)
the information submitted to the carrier was improperly coded and the carrier has provided to the health care provider sufficient information regarding the coding guidelines used by the carrier at least 30 days prior to the date the services subject to the retroactive denial were rendered;
(iii)
the claim submitted to the carrier was a duplicate claim; or
(iv)
for a claim submitted to a managed care organization, the claim was for services provided to a Maryland Medical Assistance Program recipient during a time period for which the Program has permanently retracted the capitation payment for the Program recipient from the managed care organization.
(2)
Information submitted to the carrier may be considered to be improperly coded under paragraph (1) of this subsection if the information submitted to the carrier by the health care provider:
(i)
uses codes that do not conform with the coding guidelines used by the carrier applicable as of the date the service or services were rendered; or
(ii)
does not otherwise conform with the contractual obligations of the health care provider to the carrier applicable as of the date the service or services were rendered.
(f)
If a carrier retroactively denies reimbursement for services as a result of coordination of benefits under provisions of subsection (c)(1)(i) of this section, the health care provider shall have 6 months from the date of denial, unless a carrier permits a longer time period, to submit a claim for reimbursement for the service to the carrier, Maryland Medical Assistance Program, or Medicare Program responsible for payment.
Md. Code Ann., Ins. § 15-1009 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1009LinkCopy Citation
(a)
In this section, “carrier” means:
(1)
an insurer;
(2)
a nonprofit health service plan;
(3)
a health maintenance organization;
(4)
a dental plan organization; or
(5)
any other person that provides health benefit plans subject to regulation by the State.
(b)
If a health care service for a patient has been preauthorized or approved by a carrier or the carrier’s private review agent, the carrier may not deny reimbursement to a health care provider for the preauthorized or approved service delivered to that patient unless:
(1)
the information submitted to the carrier regarding the service to be delivered to the patient was fraudulent or intentionally misrepresentative;
(2)
critical information requested by the carrier regarding the service to be delivered to the patient was omitted such that the carrier’s determination would have been different had it known the critical information;
(3)
a planned course of treatment for the patient that was approved by the carrier was not substantially followed by the health care provider; or
(4)
on the date the preauthorized or approved service was delivered:
(i)
the patient was not covered by the carrier;
(ii)
the carrier maintained an automated eligibility verification system that was available to the contracting provider by telephone or via the Internet; and
(iii)
according to the verification system, the patient was not covered by the carrier.
(c)
Notwithstanding subsection (b) of this section, a carrier may suspend review of a claim for reimbursement of a preauthorized or approved health care service if:
(1)
the patient is in the second or third month of a grace period under 45 C.F.R. § 156.270(d);
(2)
the carrier maintains an automated eligibility verification system that was available to the health care provider by telephone or via the Internet at the time the health care service was provided;
(3)
according to the verification system, the provider is informed that:
(i)
the patient is in the second or third month of a grace period and review of a claim for reimbursement may be suspended; and
(ii)
a carrier is not prohibited from denying a claim for reimbursement of a suspended claim; and
(4)
the carrier complies with the notice and claim payment requirements under § 15–1005 of this subtitle.
(d)
A carrier shall pay a claim for a preauthorized or approved covered health care service in accordance with §§ 15–1005 and 15–1008 of this subtitle.
Md. Code Ann., Ins. § 15-1010 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1010LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Adverse benefit determination” means:
(i)
a denial, reduction, or termination of a disability benefit;
(ii)
a failure to provide or make payment, in whole or in part, for a disability benefit; or
(iii)
any denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual’s eligibility for coverage of a disability benefit.
(3)
(i)
“Disability benefit” means a benefit that is payable based on the disability of a covered individual.
(ii)
“Disability benefit” does not include:
(1)
long–term care insurance;
(2)
a benefit that is payable based solely on a dismemberment of a covered individual;
(3)
benefits in a life insurance policy that operate to safeguard the contract from lapse or to provide a special surrender value, special benefit, or annuity in the event of total and permanent disability; or
(4)
benefits in a health insurance policy that operate to safeguard the contract from lapse due to disability.
(b)
(1)
The Commissioner shall adopt regulations that establish standards governing the processing of claims by an insurer that:
(i)
issues or delivers individual policies in the State that include a disability benefit; or
(ii)
issues or delivers group policies in the State that include a disability benefit.
(2)
The regulations adopted under this subsection shall establish and maintain reasonable claims procedures governing the filing of disability benefit claims, including:
(i)
notification of an adverse benefit determination; and
(ii)
an appeal by an insured or the insured’s authorized representative of an insurer’s adverse benefit determination.
(3)
The claims procedures established for both individual and group policies under this subsection shall be consistent with the provisions of the Department of Labor’s regulation entitled “Employee Retirement Income Security Act of 1974, Rules and Regulations for Administration and Enforcement; Claims Procedure; Final Rule” (29 C.F.R. 2560).
Md. Code Ann., Ins. § 15-1011 (2026)
Title 15. Health Insurance
Subtitle 10. Claims and Utilization Review
§ 15–1011LinkCopy Citation
(a)
(1)
This section applies to:
(i)
insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(ii)
health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(2)
This section does not apply to claims for reimbursement:
(i)
for services received under Medicare supplemental policies or contracts; or
(ii)
for pharmaceutical or vision services.
(b)
An entity subject to this section shall permit an insured, a subscriber, or a member seeking reimbursement for expenses incurred by the insured, subscriber, or member, in connection with a covered service provided in the United States, to submit a claim for reimbursement:
(1)
by first–class mail; and
(2)
at the election of the entity:
(i)
by facsimile transmission; or
(ii)
through a Web site that allows for the secure transmission of information.
(c)
An entity subject to this section annually shall provide:
(1)
a notice that a claims form may be submitted:
(i)
by first–class mail; and
(ii)
at the election of the entity:
(1)
by facsimile transmission; or
(2)
through a Web site that allows for the secure transmission of information; and
(2)
instructions on how to submit a claim by facsimile transmission or through a secure Web site.
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
Md. Code Ann., Ins. § 15-10A-01 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-01LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
(1)
“Adverse decision” means:
(i)
a utilization review determination by a private review agent, a carrier, or a health care provider acting on behalf of a carrier that:
(1)
a proposed or delivered health care service covered under the member’s contract is or was not medically necessary, appropriate, or efficient; and
(2)
may result in noncoverage of the health care service; or
(ii)
a denial by a carrier of a request by a member for an alternative standard or a waiver of a standard to satisfy the requirements of a wellness program under § 15–509 of this title.
(2)
“Adverse decision” includes a utilization review determination based on a prior authorization or step therapy requirement.
(3)
“Adverse decision” does not include a decision concerning a subscriber’s status as a member.
(c)
“Carrier” means a person that offers a health benefit plan and is:
(1)
an authorized insurer that provides health insurance in the State;
(2)
a nonprofit health service plan;
(3)
a health maintenance organization;
(4)
a dental plan organization;
(5)
a self–funded student health plan operated by an independent institution of higher education, as defined in § 10–101 of the Education Article, that provides health care to its students and their dependents; or
(6)
except for a managed care organization as defined in Title 15, Subtitle 1 of the Health – General Article, any other person that provides health benefit plans subject to regulation by the State.
(d)
“Complaint” means a protest filed with the Commissioner involving an adverse decision or grievance decision concerning the member.
(e)
“Designee of the Commissioner” means any person to whom the Commissioner has delegated the authority to review and decide complaints filed under this subtitle, including an administrative law judge to whom the authority to conduct a hearing has been delegated for recommended or final decision.
(f)
“Grievance” means a protest filed by a member, a member’s representative, or a health care provider on behalf of a member with a carrier through the carrier’s internal grievance process regarding an adverse decision concerning the member.
(g)
“Grievance decision” means a final determination by a carrier that arises from a grievance filed with the carrier under its internal grievance process regarding an adverse decision concerning a member.
(h)
“Health Advocacy Unit” means the Health Education and Advocacy Unit in the Division of Consumer Protection of the Office of the Attorney General established under Title 13, Subtitle 4A of the Commercial Law Article.
(i)
“Health benefit plan” has the meaning stated in § 2–112.2(a) of this article.
(j)
“Health care provider” means:
(1)
an individual who is licensed under the Health Occupations Article to provide health care services in the ordinary course of business or practice of a profession and is a treating provider of the member; or
(2)
a hospital, as defined in § 19–301 of the Health – General Article.
(k)
“Health care service” means a health or medical care procedure or service rendered by a health care provider that:
(1)
provides testing, diagnosis, or treatment of a human disease or dysfunction;
(2)
dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; or
(3)
provides any other care, service, or treatment of disease or injury, the correction of defects, or the maintenance of physical or mental well–being of individuals.
(l)
(1)
“Member” means a person entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by a carrier.
(2)
“Member” includes:
(i)
a subscriber; and
(ii)
unless preempted by federal law, a Medicare recipient.
(3)
“Member” does not include a Medicaid recipient.
(m)
“Member’s representative” means an individual who has been authorized by the member to file a grievance or a complaint on the member’s behalf.
(n)
“Private review agent” has the meaning stated in § 15–10B–01 of this title.
Md. Code Ann., Ins. § 15-10A-01.1 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-01.1LinkCopy Citation
This subtitle applies to a health benefit plan that:
(1)
is delivered or issued in the State; or
(2)
covers individuals who reside or work in the State if the health benefit plan is delivered or issued in a state that the Commissioner determines does not have an external complaint process for adverse decisions or grievances comparable to the complaint process established in this subtitle.
Md. Code Ann., Ins. § 15-10A-02 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-02LinkCopy Citation
(a)
Each carrier shall establish an internal grievance process for its members.
(b)
(1)
An internal grievance process shall meet the same requirements established under Subtitle 10B of this title.
(2)
In addition to the requirements of Subtitle 10B of this title, an internal grievance process established by a carrier under this section shall:
(i)
include an expedited procedure for use in an emergency case for purposes of rendering a grievance decision within 24 hours of the date a grievance is filed with the carrier;
(ii)
provide that a carrier render a final decision in writing on a grievance within 30 working days after the date on which the grievance is filed unless:
(1)
the grievance involves an emergency case under item (i) of this paragraph;
(2)
the member, the member’s representative, or a health care provider filing a grievance on behalf of a member agrees in writing to an extension for a period of no longer than 30 working days; or
(3)
the grievance involves a retrospective denial under item (iv) of this paragraph;
(iii)
allow a grievance to be filed on behalf of a member by a health care provider or the member’s representative;
(iv)
provide that a carrier render a final decision in writing on a grievance within 45 working days after the date on which the grievance is filed when the grievance involves a retrospective denial; and
(v)
for a retrospective denial, allow a member, the member’s representative, or a health care provider on behalf of a member to file a grievance for at least 180 days after the member receives an adverse decision.
(3)
For purposes of using the expedited procedure for an emergency case that a carrier is required to include under paragraph (2)(i) of this subsection, the carrier shall initiate the expedited procedure for an emergency case if the member or the member’s representative requests the expedited review or the health care provider or the member or the member’s representative attests that:
(i)
the adverse decision was rendered for health care services that are proposed but have not been provided; and
(ii)
the services are necessary to treat a condition or illness that, without immediate medical attention, would:
(1)
seriously jeopardize the life or health of the member or the member’s ability to regain maximum functions;
(2)
cause the member to be in danger to self or others; or
(3)
cause the member to continue using intoxicating substances in an imminently dangerous manner.
(c)
Except as provided in subsection (d) of this section, the carrier’s internal grievance process shall be exhausted prior to filing a complaint with the Commissioner under this subtitle.
(d)
(1)
(i)
A member, the member’s representative, or a health care provider filing a complaint on behalf of a member may file a complaint with the Commissioner without first filing a grievance with a carrier and receiving a final decision on the grievance if:
(1)
the carrier waives the requirement that the carrier’s internal grievance process be exhausted before filing a complaint with the Commissioner;
(2)
the carrier has failed to comply with any of the requirements of the internal grievance process as described in this section; or
(3)
the member, the member’s representative, or the health care provider provides sufficient information and supporting documentation in the complaint that demonstrates a compelling reason to do so.
(ii)
The Commissioner shall define by regulation the standards that the Commissioner shall use to decide what demonstrates a compelling reason under subparagraph (i) of this paragraph.
(2)
Subject to subsections (b)(2)(ii) and (h) of this section, a member, a member’s representative, or a health care provider may file a complaint with the Commissioner if the member, the member’s representative, or the health care provider does not receive a grievance decision from the carrier on or before the 30th working day on which the grievance is filed.
(3)
Whenever the Commissioner receives a complaint under paragraph (1) or (2) of this subsection, the Commissioner shall notify the carrier that is the subject of the complaint within 5 working days after the date the complaint is filed with the Commissioner.
(e)
Each carrier shall:
(1)
file for review with the Commissioner and submit to the Health Advocacy Unit a copy of its internal grievance process established under this subtitle; and
(2)
file any revision to the internal grievance process with the Commissioner and the Health Advocacy Unit at least 30 days before its intended use.
(f)
(1)
For nonemergency cases, when a carrier renders an adverse decision, the carrier shall:
(i)
inform the member, the member’s representative, or the health care provider acting on behalf of the member of the adverse decision:
(1)
orally by telephone; or
(2)
with the affirmative consent of the member, the member’s representative, or the health care provider acting on behalf of the member, by text, facsimile, e–mail, an online portal, or other expedited means; and
(ii)
send, within 5 working days after the adverse decision has been made, a written notice to the member, the member’s representative, and a health care provider acting on behalf of the member that:
(1)
states at the top in prominent bold print:
(A)
that the notice is a denial of a requested health care service;
(B)
that the member may file an appeal;
(C)
the telephone number and e–mail address required to be available under § 15–10B–05(e) of this title; and
(D)
that the notice includes additional information on how to file and receive assistance for filing a complaint;
(2)
states in detail in clear, understandable language the specific factual bases for the carrier’s decision and the reasoning used to determine that the health care service is not medically necessary and did not meet the carrier’s criteria and standards used in conducting the utilization review;
(3)
provides the specific reference, language, or requirements from the criteria and standards, including any interpretive guidelines, on which the decision was based, and may not solely use:
(A)
generalized terms such as “experimental procedure not covered”, “cosmetic procedure not covered”, “service included under another procedure”, or “not medically necessary”; or
(B)
language directing the member to review the additional coverage criteria in the member’s policy or plan documents;
(4)
includes a unique identifier for and the business address and business telephone number of:
(A)
if the carrier is a health maintenance organization, the medical director or associate medical director, as appropriate, who made the decision; or
(B)
if the carrier is not a health maintenance organization, the designated employee or representative of the carrier who has responsibility for the carrier’s internal grievance process and the physician who is required to make all adverse decisions as required in § 15–10B–07(a) of this title;
(5)
gives written details of the carrier’s internal grievance process and procedures under this subtitle; and
(6)
includes the following information:
(A)
that the member, the member’s representative, or a health care provider on behalf of the member has a right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s grievance decision;
(B)
that a complaint may be filed without first filing a grievance if the member, the member’s representative, or a health care provider filing a grievance on behalf of the member can demonstrate a compelling reason to do so as determined by the Commissioner;
(C)
the Commissioner’s address, telephone number, and facsimile number;
(D)
a statement that the Health Advocacy Unit is available to assist the member or the member’s representative in both mediating and filing a grievance under the carrier’s internal grievance process; and
(E)
the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.
(2)
The business telephone number included in the notice as required under paragraph (1)(ii)4 of this subsection must be a dedicated number for adverse decisions and may not be the general customer call number for the carrier.
(g)
If within 5 working days after a member, the member’s representative, or a health care provider, who has filed a grievance on behalf of a member, files a grievance with the carrier, and if the carrier does not have sufficient information to complete its internal grievance process, the carrier shall:
(1)
after confirming through a complete review of any information already submitted by the health care provider:
(i)
notify the member, the member’s representative, or the health care provider that it cannot proceed with reviewing the grievance unless additional information is provided;
(ii)
request the specific information, including any lab or diagnostic test or other medical information that must be submitted to complete the internal grievance process; and
(iii)
provide the specific reference, language, or requirements from the criteria and standards used by the carrier to support the need for the additional information; and
(2)
assist the member, the member’s representative, or the health care provider in gathering the necessary information without further delay.
(h)
A carrier may extend the 30–day or 45–day period required for making a final grievance decision under subsection (b)(2)(ii) of this section with the written consent of the member, the member’s representative, or the health care provider who filed the grievance on behalf of the member.
(i)
(1)
For nonemergency cases, when a carrier renders a grievance decision, the carrier shall:
(i)
document the grievance decision in writing after the carrier has provided oral communication of the decision to the member, the member’s representative, or the health care provider acting on behalf of the member; and
(ii)
send, within 5 working days after the grievance decision has been made, a written notice to the member, the member’s representative, and a health care provider acting on behalf of the member that:
(1)
states at the top in prominent bold print:
(A)
that the notice is a denial of a requested health care service;
(B)
that the member may file a complaint with the Commissioner;
(C)
the telephone number and e–mail address required to be available under § 15–10B–05(e) of this title; and
(D)
that the notice includes additional information on how to file and receive assistance for an appeal;
(2)
states in detail in clear, understandable language the specific factual bases for the carrier’s decision and the reasoning used to determine that the health care service is not medically necessary and did not meet the carrier’s criteria and standards used in conducting utilization review;
(3)
provides the specific reference, language, or requirements from the criteria and standards, including any interpretive guidelines used by the carrier, on which the grievance decision was based;
(4)
includes a unique identifier for and the business address and business telephone number of:
(A)
if the carrier is a health maintenance organization, the medical director or associate medical director, as appropriate, who made the grievance decision; or
(B)
if the carrier is not a health maintenance organization, the designated employee or representative of the carrier who has responsibility for the carrier’s internal grievance process and the designated employee or representative’s title and clinical specialty; and
(5)
includes the following information:
(A)
that the member or the member’s representative has a right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s grievance decision;
(B)
the Commissioner’s address, telephone number, and facsimile number;
(C)
a statement that the Health Advocacy Unit is available to assist the member or the member’s representative in filing a complaint with the Commissioner; and
(D)
the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.
(2)
The business telephone number included in the notice as required under paragraph (1)(ii)4 of this subsection must be a dedicated number for grievance decisions and may not be the general customer call number for the carrier.
(3)
To satisfy the requirements of this subsection, a carrier may not use solely in the written notice sent under paragraph (1) of this subsection:
(i)
generalized terms such as “experimental procedure not covered”, “cosmetic procedure not covered”, “service included under another procedure”, or “not medically necessary”; or
(ii)
language directing the member to review the additional coverage criteria in the member’s policy or plan documents.
(j)
(1)
For an emergency case under subsection (b)(2)(i) of this section, within 1 day after a decision has been orally communicated to the member, the member’s representative, or the health care provider, the carrier shall send notice in writing of any adverse decision or grievance decision to:
(i)
the member and the member’s representative, if any; and
(ii)
if the grievance was filed on behalf of the member under subsection (b)(2)(iii) of this section, the health care provider.
(2)
A notice required to be sent under paragraph (1) of this subsection shall include the following:
(i)
for an adverse decision, the information required under subsection (f) of this section; and
(ii)
for a grievance decision, the information required under subsection (i) of this section.
(k)
(1)
Each carrier shall include the information required by subsection (f)(1)(ii)3, 4, and 5 of this section in the policy, plan, certificate, enrollment materials, or other evidence of coverage that the carrier provides to a member at the time of the member’s initial coverage or renewal of coverage.
(2)
Each carrier shall include as part of the information required by paragraph (1) of this subsection a statement indicating that, when filing a complaint with the Commissioner, the member or the member’s representative will be required to authorize the release of any medical records of the member that may be required to be reviewed for the purpose of reaching a decision on the complaint.
(l)
(1)
Nothing in this subtitle prohibits a carrier from delegating its internal grievance process to a private review agent that has a certificate issued under Subtitle 10B of this title and is acting on behalf of the carrier.
(2)
If a carrier delegates its internal grievance process to a private review agent, the carrier shall be:
(i)
bound by the grievance decision made by the private review agent acting on behalf of the carrier; and
(ii)
responsible for a violation of any provision of this subtitle regardless of the delegation made by the carrier under paragraph (1) of this subsection.
Md. Code Ann., Ins. § 15-10A-03 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-03LinkCopy Citation
(a)
(1)
Within 4 months after the date of receipt of an adverse decision or a grievance decision, a member, a member’s representative, or a health care provider, who filed the grievance on behalf of the member under § 15–10A–02(b)(2)(iii) of this subtitle, may file a complaint with the Commissioner.
(2)
Whenever the Commissioner receives a complaint under this subsection, the Commissioner shall notify the carrier that is the subject of the complaint within 5 working days after the date the complaint is filed with the Commissioner.
(3)
Except for an emergency case under subsection (b)(1)(ii) of this section, the carrier that is the subject of a complaint filed under paragraph (1) of this subsection shall provide to the Commissioner any information requested by the Commissioner no later than 7 working days from the date the carrier receives the request for information.
(b)
(1)
In developing procedures to be used in reviewing and deciding complaints, the Commissioner shall:
(i)
allow a health care provider to file a complaint on behalf of a member; and
(ii)
establish an expedited procedure for use in an emergency case for the purpose of making a final decision on a complaint within 24 hours after the complaint is filed with the Commissioner.
(2)
For purposes of using the expedited procedure for an emergency case under paragraph (1)(ii) of this subsection, the Commissioner shall define by regulation the standards required for a grievance to be considered an emergency case.
(c)
(1)
Except as provided in paragraph (2) of this subsection and except for an emergency case under subsection (b)(1)(ii) of this section, the Commissioner shall make a final decision on a complaint:
(i)
within 45 days after a complaint regarding a pending health care service is filed; and
(ii)
within 45 days after a complaint is filed regarding a retrospective denial of services already provided.
(2)
The Commissioner may extend the period within which a final decision is to be made under paragraph (1) of this subsection for up to an additional 30 working days if:
(i)
the Commissioner has not yet received information requested by the Commissioner; and
(ii)
the information requested is necessary for the Commissioner to render a final decision on the complaint.
(d)
The Commissioner shall seek advice from an independent review organization or medical expert, as provided in § 15–10A–05 of this subtitle, for complaints filed with the Commissioner under this subtitle that involve a question of whether a health care service provided or to be provided to a member is medically necessary.
(e)
(1)
A carrier shall have the burden of persuasion that its adverse decision or grievance decision, as applicable, is correct:
(i)
during the review of a complaint by the Commissioner or a designee of the Commissioner; and
(ii)
in any hearing held in accordance with § 2–210 of this article.
(2)
As part of the review of a complaint, the Commissioner or a designee of the Commissioner may consider all of the facts of the case and any other evidence that the Commissioner or designee of the Commissioner considers appropriate.
(3)
As required under § 15–10A–02(i) of this subtitle, the carrier’s adverse decision or grievance decision shall state in detail in clear, understandable language the factual bases for the decision and reference the specific criteria and standards, including interpretive guidelines on which the decision was based.
(4)
(i)
Except as provided in subparagraph (ii) of this paragraph, in responding to a complaint, a carrier may not rely on any basis not stated in its adverse decision or grievance decision.
(ii)
The Commissioner may allow a carrier, a member, a member’s representative, or a health care provider filing a complaint on behalf of a member to provide additional information as may be relevant for the Commissioner to make a final decision on the complaint.
(iii)
The Commissioner shall allow the member, the member’s representative, or the health care provider filing a complaint on behalf of the member at least 5 working days to provide the additional information described in subparagraph (ii) of this paragraph.
(iv)
The Commissioner’s use of additional information may not delay the Commissioner’s decision on the complaint by more than 5 working days.
(f)
The Commissioner may request the member that filed the complaint or a legally authorized designee of the member to sign a consent form authorizing the release of the member’s medical records to the Commissioner or the Commissioner’s designee that are needed in order for the Commissioner to make a final decision on the complaint.
Md. Code Ann., Ins. § 15-10A-04 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-04LinkCopy Citation
(a)
The Commissioner shall:
(1)
notwithstanding the provisions of § 15–10A–03(c)(1)(ii) of this subtitle, for the purpose of making final decisions on complaints, prioritize complaints regarding pending health care services over complaints regarding health care services already delivered;
(2)
make and issue in writing a final decision on all complaints filed with the Commissioner under this subtitle that are within the Commissioner’s jurisdiction; and
(3)
provide notice in writing to all parties to a complaint of the available remedy to the party described under subsection (e) of this section and the time period for requesting the remedy.
(b)
(1)
For emergency cases, the Commissioner shall send written notification of the Commissioner’s final decision within 1 working day after the Commissioner or the Commissioner’s designee has informed the member or a health care provider who filed the complaint on behalf of the member of the final decision through an oral communication.
(2)
The Commissioner shall include in the notice the information required under subsection (a)(3) of this section.
(c)
(1)
It is a violation of this subtitle for a carrier to fail to fulfill the carrier’s obligations to provide or reimburse for health care services specified in the carrier’s policies or contracts with members.
(2)
If, in rendering an adverse decision or grievance decision, a carrier fails to fulfill the carrier’s obligations to provide or reimburse for health care services specified in the carrier’s policies or contracts with members, the Commissioner may:
(i)
issue an administrative order that requires the carrier to:
(1)
cease inappropriate conduct or practices by the carrier or any of the personnel employed or associated with the carrier;
(2)
fulfill the carrier’s contractual obligations;
(3)
provide a health care service or payment that has been denied improperly; or
(4)
take appropriate steps to restore the carrier’s ability to provide a health care service or payment that is provided under a contract; or
(ii)
impose any penalty or fine or take any action as authorized:
(1)
for an insurer, nonprofit health service plan, or dental plan organization, under this article; or
(2)
for a health maintenance organization, under the Health – General Article or under this article.
(3)
In addition to paragraph (1) of this subsection, it is a violation of this subtitle, if the Commissioner, in consultation with an independent review organization, medical expert, the Department, or other appropriate entity, determines that the criteria and standards used by a health maintenance organization to conduct utilization review are not in accordance with § 15–10B–05 of this title.
(d)
The Commissioner may refer complaints not within the Commissioner’s jurisdiction to the Health Advocacy Unit or any other appropriate federal or State government agency or unit for disposition or resolution.
(e)
(1)
A final decision of the Commissioner made on a complaint under this subtitle:
(i)
is not subject to a request for a hearing under this subtitle for a carrier; and
(ii)
is subject to a right to file a petition for judicial review under § 2–215 of this article for a carrier or a member.
(2)
Unless prohibited under federal law, a member may request a hearing to be held in accordance with § 2–210 of this article of a final decision of the Commissioner made on a complaint under this subtitle.
Md. Code Ann., Ins. § 15-10A-05 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-05LinkCopy Citation
(a)
For a complaint filed with the Commissioner under this subtitle that involves a question of whether the health care service provided or to be provided to a member is medically necessary, the Commissioner:
(1)
shall select an independent review organization or medical expert to advise on the complaint; and
(2)
may accept and base the final decision on the complaint on the professional judgment of an independent review organization or medical expert.
(b)
To ensure access to advice when needed, the Commissioner, in consultation with the Secretary of Health and carriers, shall compile a list of independent review organizations and medical experts.
(c)
Any expert reviewer assigned by an independent review organization or medical expert shall be a physician or other appropriate health care provider who meets the following minimum requirements:
(1)
be an expert in the treatment of the member’s medical condition, and knowledgeable about the recommended health care service or treatment through actual clinical experience;
(2)
hold:
(i)
a nonrestricted license in a state of the United States; and
(ii)
in addition, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of review; and
(3)
have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that the Commissioner, in accordance with regulations adopted by the Commissioner, considers relevant in meeting the requirements of this subsection.
(d)
An independent review organization may not be a subsidiary of, or in any way owned or controlled by, a health benefit plan, or a trade association of health benefit plans, or a trade association of health care providers.
(e)
In addition to subsection (d) of this section, to be included on the list compiled under subsection (b) of this section, an independent review organization shall submit to the Commissioner the following information:
(1)
if the independent review organization is a publicly held organization, the names of all stockholders and owners of more than 5% of any stock or options of the independent review organization;
(2)
the names of all holders of bonds or notes in excess of $100,000, if any;
(3)
the names of all corporations and organizations that the independent review organization controls or is affiliated with, and the nature and extent of any ownership or control, including the affiliated organization’s type of business;
(4)
the names of all directors, officers, and executives of the independent review organization as well as a statement regarding any relationships the directors, officers, and executives may have with any carrier or health care provider group; and
(5)
evidence, in the form required by the Commissioner, that the independent review organization is accredited by a nationally recognized private accrediting organization.
(f)
An expert reviewer assigned by an independent review organization or the independent review organization or medical expert selected by the Commissioner under this section may not have a material professional, familial, or financial conflict of interest with any of the following:
(1)
the carrier that is the subject of the complaint;
(2)
any officer, director, or management employee of the carrier that is the subject of the complaint;
(3)
the health care provider, the health care provider’s medical group, or the independent practice association that rendered or is proposing to render the health care service that is under review;
(4)
the health care facility at which the health care service was provided or will be provided; or
(5)
the developer or manufacturer of the principal drug, device, procedure, or other therapy that is being proposed for the member.
(g)
For any independent review organization selected by the Commissioner under subsection (a) of this section, the independent review organization shall have a quality assurance mechanism in place that ensures:
(1)
the timeliness and quality of the reviews;
(2)
the qualifications and independence of the expert reviewers; and
(3)
the confidentiality of medical records and review materials.
(h)
(1)
The carrier that is the subject of the complaint shall be responsible for paying the reasonable expenses of the independent review organization or medical expert selected by the Commissioner in accordance with subsection (a) of this section.
(2)
The independent review organization or medical expert shall:
(i)
present to the carrier for payment a detailed account of the expenses incurred by the independent review organization or medical expert; and
(ii)
provide a copy of the detailed account of expenses to the Commissioner.
(3)
The carrier that is the subject of the complaint may not pay and an independent review organization or medical expert may not accept any compensation in addition to the payment for reasonable expenses under paragraph (1) of this subsection.
Md. Code Ann., Ins. § 15-10A-06 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-06LinkCopy Citation
(a)
(1)
On a quarterly basis, each carrier shall submit to the Commissioner, on the form the Commissioner requires, a report that describes the following information aggregated by zip code as required by the Commissioner:
(i)
the number of members entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by the carrier;
(ii)
the number of clean claims for reimbursement processed by the carrier;
(iii)
the activities of the carrier under this subtitle, including:
(1)
the outcome of each grievance filed with the carrier;
(2)
the number and outcomes of cases that were considered emergency cases under § 15–10A–02(b)(2)(i) of this subtitle;
(3)
the time within which the carrier made a grievance decision on each emergency case;
(4)
the time within which the carrier made a grievance decision on all other cases that were not considered emergency cases;
(5)
the number of grievances filed with the carrier that resulted from an adverse decision involving length of stay for inpatient hospitalization as related to the medical procedure involved;
(6)
the number of adverse decisions issued by the carrier under § 15–10A–02(f) of this subtitle, whether the adverse decision involved a prior authorization or step therapy protocol, the type of service at issue in the adverse decisions, and whether an artificial intelligence, algorithm, or other software tool was used in making the adverse decision;
(7)
the number of adverse decisions overturned after a reconsideration request under § 15–10B–06 of this title; and
(8)
the number of requests made and granted under § 15–831(c)(1) and (2) of this title; and
(iv)
the number and outcome of all other cases that are not subject to activities of the carrier under this subtitle that resulted from an adverse decision involving the length of stay for inpatient hospitalization as related to the medical procedure involved.
(2)
If the number of adverse decisions issued by a carrier for a type of service has grown by 10% or more in the immediately preceding calendar year or 25% or more in the immediately preceding 3 calendar years, the carrier shall submit in the report required under paragraph (1) of this subsection:
(i)
a description of any changes in medical management contributing to the rise in adverse decisions for the type of service;
(ii)
any other known reasons for the increase; and
(iii)
a description of the carrier’s efforts and actions taken to determine the reason for the increase.
(b)
The Commissioner shall:
(1)
compile an annual summary report based on the information provided:
(i)
under subsection (a) of this section; and
(ii)
by the Secretary under § 19–705.2(e) of the Health – General Article;
(2)
include in the summary report data on adverse decisions and grievances related to post–acute services, including adverse decisions and grievances relating to admissions to skilled nursing facilities and inpatient rehabilitation facilities;
(3)
report any violations or actions taken under § 15–10B–11 of this title; and
(4)
provide copies of the summary report to the Governor and, subject to § 2–1257 of the State Government Article, to the General Assembly.
(c)
The Commissioner may use information provided under subsection (a) of this section as the basis for an examination under Title 2, Subtitle 2 of this article.
Md. Code Ann., Ins. § 15-10A-07 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-07LinkCopy Citation
On a quarterly basis, the Health Advocacy Unit shall submit a report to the Commissioner that:
(1)
describes activities it performed on behalf of members that have participated in an internal grievance process of a carrier established under this subtitle;
(2)
describes its efforts to mediate cases that involve an adverse decision;
(3)
names each carrier involved in the cases described in the report;
(4)
states the number and outcome of each grievance considered an emergency case under § 15-10A-02(b)(2)(i) of this subtitle described in the report, including the time within which the carrier made a grievance decision on each emergency case; and
(5)
states the number and outcome of each case described in the report that was not considered an emergency case, including the time within which the carrier made a grievance decision on the case.
Md. Code Ann., Ins. § 15-10A-08 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-08LinkCopy Citation
(a)
On or before November 1, 1999, and each November 1 thereafter, the Health Advocacy Unit shall publish an annual summary report and provide copies of the report to the Governor and, subject to § 2–1257 of the State Government Article, the General Assembly.
(b)
(1)
The annual summary report required under subsection (a) of this section shall be on the grievances and complaints filed with or referred to a carrier, the Commissioner, the Health Advocacy Unit, or any other federal or State government agency or unit under this subtitle during the previous fiscal year.
(2)
In consultation with the Commissioner and any affected State government agency or unit, the Health Advocacy Unit shall:
(i)
evaluate the effectiveness of the internal grievance process and complaint process available to members; and
(ii)
include in the annual summary report the results of the evaluation and any proposed changes to the law that it considers necessary to ensure compliance with the purposes of the law.
Md. Code Ann., Ins. § 15-10A-09 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-09LinkCopy Citation
(a)
The Commissioner shall adopt regulations to carry out this subtitle.
(b)
In addition to the requirements of subsection (a) of this section, the Commissioner shall adopt by regulation a requirement that each carrier provide a mechanism in a form and manner that the Commissioner may require to enable a member to:
(1)
be informed of the member’s right to challenge a decision made by a carrier that resulted in the nonpayment of a health care service; and
(2)
access the Consumer Education and Advocacy Program in the Administration.
Md. Code Ann., Ins. § 15-10A-10 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-10LinkCopy Citation
A carrier shall provide the notices required to be provided to members under this subtitle in a culturally and linguistically appropriate manner as described in the Affordable Care Act.
Subtitle 10B. Private Review Agents
Md. Code Ann., Ins. § 15-10B-01 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-01LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
(1)
“Adverse decision” means a utilization review determination made by a private review agent that a proposed or delivered health care service:
(i)
is or was not medically necessary, appropriate, or efficient; and
(ii)
may result in noncoverage of the health care service.
(2)
“Adverse decision” includes a utilization review determination based on a prior authorization or step therapy requirement.
(3)
“Adverse decision” does not include a decision concerning a subscriber’s status as a member.
(c)
“Certificate” means a certificate of registration granted by the Commissioner to a private review agent.
(d)
(1)
“Employee assistance program” means a health care service plan that, in accordance with a contract with an employer or labor union:
(i)
consults with employees or members of an employee’s family or both to:
(1)
identify the employee’s or the employee’s family member’s mental health, alcohol, or substance abuse problems; and
(2)
refer the employee or the employee’s family member to health care providers or other community resources for counseling, therapy, or treatment; and
(ii)
performs utilization review for the purpose of making claims or payment decisions on behalf of the employer’s or labor union’s health insurance or health benefit plan.
(2)
“Employee assistance program” does not include a health care service plan operated by a hospital solely for employees, or members of an employee’s family, of that hospital.
(e)
(1)
“Grievance” means a protest filed by a patient or a health care provider on behalf of a patient with a private review agent through the private review agent’s internal grievance process regarding an adverse decision concerning a patient.
(2)
“Grievance” does not include a verbal request for reconsideration of a utilization review determination.
(f)
“Grievance decision” means a final determination by a private review agent that arises from a grievance filed with the private review agent under its internal grievance process regarding an adverse decision concerning a patient.
(g)
“Health care facility” means:
(1)
a hospital as defined in § 19–301 of the Health – General Article;
(2)
a related institution as defined in § 19–301 of the Health – General Article;
(3)
an ambulatory surgical facility or center which is any entity or part thereof that operates primarily for the purpose of providing surgical services to patients not requiring hospitalization and seeks reimbursement from third party payors as an ambulatory surgical facility or center;
(4)
a facility that is organized primarily to help in the rehabilitation of disabled individuals;
(5)
a home health agency as defined in § 19–401 of the Health – General Article;
(6)
a hospice as defined in § 19–901 of the Health – General Article;
(7)
a facility that provides radiological or other diagnostic imagery services;
(8)
a medical laboratory as defined in § 17–201 of the Health – General Article; or
(9)
an alcohol abuse and drug abuse treatment program as defined in § 8–403 of the Health – General Article.
(h)
“Health care provider” means:
(1)
an individual who:
(i)
is licensed or otherwise authorized to provide health care services in the ordinary course of business or practice of a profession; and
(ii)
is a treating provider of a patient; or
(2)
a hospital, as defined in § 19–301 of the Health – General Article.
(i)
“Health care service” means a health or medical care procedure or service rendered by a health care provider licensed or authorized to provide health care services that:
(1)
provides testing, diagnosis, or treatment of a human disease or dysfunction;
(2)
dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; or
(3)
provides any other care, service, or treatment of disease or injury, the correction of defects, or the maintenance of the physical and mental well–being of human beings.
(j)
“Health care service reviewer” means an individual who is licensed or otherwise authorized to provide health care services in the ordinary course of business or practice of a profession.
(k)
“Private review agent” means:
(1)
a nonhospital–affiliated person or entity performing utilization review that is either affiliated with, under contract with, or acting on behalf of:
(i)
a Maryland business entity; or
(ii)
a third party that pays for, provides, or administers health care services to citizens of this State; or
(2)
any person or entity including a hospital–affiliated person performing utilization review for the purpose of making claims or payment decisions for health care services on behalf of the employer’s or labor union’s health insurance plan under an employee assistance program for employees other than the employees employed by:
(i)
the hospital; or
(ii)
a business wholly owned by the hospital.
(l)
“Significant beneficial interest” means the ownership of any financial interest that is greater than the lesser of:
(1)
5 percent of the whole; or
(2)
$5,000.
(m)
“Utilization review” means a system for reviewing the appropriate and efficient allocation of health care resources and services given or proposed to be given to a patient or group of patients.
(n)
“Utilization review plan” means a description of the standards governing utilization review activities performed by a private review agent.
Md. Code Ann., Ins. § 15-10B-02 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-02LinkCopy Citation
The purpose of this subtitle is to:
(1)
promote the delivery of quality health care in a cost effective manner that ensures timely access to health care services;
(2)
foster greater coordination, communication, and transparency between payors, patients, and providers conducting utilization review activities;
(3)
protect patients, business, and providers by ensuring that private review agents are qualified to perform utilization review activities and to make informed decisions on the appropriateness of medical care; and
(4)
ensure that private review agents maintain the confidentiality of medical records in accordance with applicable State and federal laws.
Md. Code Ann., Ins. § 15-10B-03 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-03LinkCopy Citation
(a)
A private review agent may not conduct utilization review in this State unless the Commissioner has granted the private review agent a certificate.
(b)
The Commissioner shall issue a certificate to an applicant that has met all the requirements of this subtitle and all applicable regulations of the Commissioner.
(c)
A certificate issued under this subtitle is not transferable.
(d)
The Commissioner may consider an applicant as having met a particular certification requirement under this subtitle if:
(1)
the applicant has obtained utilization management accreditation from an approved accrediting organization as determined by the Commissioner;
(2)
the approved accrediting organization has requirements that meet or exceed the particular requirement in this subtitle; and
(3)
the applicant demonstrates that the applicant meets or exceeds the particular requirement under this subtitle.
(e)
The Commissioner may adopt regulations to implement the provisions of this section.
(f)
The Commissioner may not issue a certificate to an applicant with utilization management accreditation by an approved accrediting organization unless the applicant meets all the requirements of this subtitle and all applicable regulations of the Commissioner.
(g)
A report of an approved accrediting organization used by the Commissioner as evidence that the applicant has met a particular requirement for a private review agent certificate shall be made available by the Commissioner to the public on request.
(h)
(1)
The Commissioner, after consultation with payors, including the Health Insurance Association of America, the League of Life and Health Insurers of Maryland, and the Maryland Association of Health Plans, and providers of health care, including the MHA: the Association of Maryland Hospitals and Health Systems, CareFirst BlueCross BlueShield, the Medical and Chirurgical Faculty of Maryland, and licensed or certified providers of treatment for a mental illness, emotional disorder, or a drug abuse or alcohol abuse disorder, shall adopt regulations to implement the provisions of this subtitle.
(2)
(i)
Subject to the provisions of subparagraph (iii) of this paragraph, the regulations adopted by the Commissioner shall include a uniform treatment plan form for utilization review of services for the treatment of a mental illness, emotional disorder, or a substance abuse disorder.
(ii)
The uniform treatment plan form adopted by the Commissioner:
(1)
shall adequately protect the confidentiality of the patient; and
(2)
may only request the patient’s membership number, policy number, or other similar unique patient identifier and first name for patient identification.
(iii)
The Commissioner may waive the requirements of regulations adopted under subparagraph (i) of this paragraph for the use of a uniform treatment plan form for any entity that would be using the form solely for internal purposes.
Md. Code Ann., Ins. § 15-10B-04 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-04LinkCopy Citation
(a)
An applicant for a certificate shall:
(1)
submit an application to the Commissioner; and
(2)
pay to the Commissioner the application fee established by the Commissioner through regulation.
(b)
The application shall:
(1)
be on a form and accompanied by any supporting documentation that the Commissioner requires; and
(2)
be signed and verified by the applicant.
(c)
The fees required under subsection (a)(2) of this section or § 15-10B-10(b)(2) of this subtitle shall be sufficient to pay for the administrative costs of the certificate program and any other costs associated with carrying out the provisions of this subtitle.
Md. Code Ann., Ins. § 15-10B-05 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-05LinkCopy Citation
(a)
In conjunction with the application, the private review agent shall submit information that the Commissioner requires including:
(1)
a utilization review plan that includes:
(i)
the specific criteria and standards to be used in conducting utilization review of proposed or delivered health care services;
(ii)
those circumstances, if any, under which utilization review may be delegated to a hospital utilization review program; and
(iii)
if applicable, any provisions by which patients or physicians, hospitals, or other health care providers may seek reconsideration;
(2)
the type and qualifications of the personnel either employed or under contract to perform the utilization review;
(3)
a copy of the private review agent’s internal grievance process if a carrier delegates its internal grievance process to the private review agent in accordance with § 15–10A–02(l) of this title;
(4)
the procedures and policies to ensure that a representative of the private review agent is reasonably accessible to patients and health care providers 7 days a week, 24 hours a day in this State including having a direct telephone number and monitored e–mail address as required in subsection (e) of this section;
(5)
if applicable, the procedures and policies to ensure that a representative of the private review agent is accessible to health care providers to make all determinations on whether to authorize or certify an emergency inpatient admission, or an admission for residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, emotional, or substance abuse disorder within 2 hours after receipt of the information necessary to make the determination;
(6)
the policies and procedures to ensure that all applicable State and federal laws to protect the confidentiality of individual medical records are followed;
(7)
a copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan;
(8)
a list of the third party payors for which the private review agent is performing utilization review in this State;
(9)
the policies and procedures to ensure that the private review agent has a formal program for the orientation and training of the personnel either employed or under contract to perform the utilization review;
(10)
a list of the persons involved in establishing the specific criteria and standards to be used in conducting utilization review, including each person’s board certification or practice specialty, licensure category, and title within the person’s organization; and
(11)
certification by the private review agent that the criteria and standards to be used in conducting utilization review are generally recognized by health care providers practicing in the relevant clinical specialties and are:
(i)
objective;
(ii)
clinically valid;
(iii)
reflected in published peer–reviewed scientific studies and medical literature;
(iv)
developed by:
(1)
a nonprofit health care provider professional medical or clinical specialty society, including through the use of patient placement criteria and clinical practice guidelines; or
(2)
for criteria not within the scope of a nonprofit health care provider professional medical or clinical specialty society, an organization that works directly with health care providers in the same specialty for the designated criteria who are employed or engaged within the organization or outside the organization to develop the clinical criteria, if the organization:
(A)
does not receive direct payments based on the outcome of the utilization review; and
(B)
demonstrates that its clinical criteria are consistent with criteria and standards generally recognized by health care providers practicing in the relevant clinical specialties;
(v)
recommended by federal agencies;
(vi)
approved by the federal Food and Drug Administration as part of drug labeling;
(vii)
taking into account the needs of atypical patient populations and diagnoses, including the unique needs of children and adolescents;
(viii)
sufficiently flexible to allow deviations from norms when justified on a case–by–case basis, including the need to use an off–label prescription drug;
(ix)
ensuring quality of care of health care services;
(x)
reviewed, evaluated, and updated at least annually and as necessary to reflect any changes; and
(xi)
in compliance with any other criteria and standards required for coverage under this title, including compliance with § 15–802(d) of this title for the treatment of substance use disorders.
(b)
The private review agent shall:
(1)
post on the member’s and provider’s pages of its website or the carrier’s website the specific criteria and standards to be used in conducting utilization review of proposed or delivered services and any subsequent revisions, modifications, or additions to the specific criteria and standards to be used in conducting utilization review of proposed or delivered services; and
(2)
on the request of a person, including a health care facility, provide a copy of the information specified under item (1) of this subsection to the person making the request.
(c)
The private review agent may charge a reasonable fee for a hard copy of the specific criteria and standards or any subsequent revisions, modifications, or additions to the specific criteria to any person or health care facility requesting a copy under subsection (b)(2) of this section.
(d)
A private review agent shall advise the Commissioner, in writing, of a change in:
(1)
ownership, medical director, or chief executive officer within 30 days of the date of the change;
(2)
the name, address, or telephone number of the private review agent within 30 days of the date of the change; or
(3)
the private review agent’s scope of responsibility under a contract.
(e)
(1)
A private review agent shall:
(i)
have available the following dedicated to utilization review:
(1)
a direct telephone number that is not the general customer call number; and
(2)
a monitored e–mail address; and
(ii)
except where a shorter time period is otherwise required under this title, respond to voicemails or e–mails within 2 business days after receipt of the voicemail or e–mail.
(2)
The telephone number and e–mail address shall be prominently displayed on the notices required under § 15–10A–02(f) and (i) of this title.
Md. Code Ann., Ins. § 15-10B-05.1 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-05.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Artificial intelligence” means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.
(3)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan;
(iii)
a health maintenance organization;
(iv)
a dental plan organization; or
(v)
any other person that provides health benefit plans subject to regulation by the State.
(b)
This section applies to:
(1)
a carrier that:
(i)
uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review; or
(ii)
contracts with or otherwise works through an entity that uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review; and
(2)
a pharmacy benefits manager or private review agent that:
(i)
contracts with a carrier to provide utilization review on behalf of the carrier; and
(ii)
uses an artificial intelligence, algorithm, or other software tool for the purpose of conducting utilization review on behalf of the carrier.
(c)
Subject to subsection (d) of this section, an entity subject to this section shall ensure that:
(1)
an artificial intelligence, algorithm, or other software tool bases its determinations on:
(i)
an enrollee’s medical or other clinical history;
(ii)
individual clinical circumstances as presented by a requesting provider; or
(iii)
other relevant clinical information contained in the enrollee’s medical or other clinical record;
(2)
an artificial intelligence, algorithm, or other software tool does not base its determinations solely on a group dataset;
(3)
the criteria and guidelines for using an artificial intelligence, algorithm, or other software tool for making determinations comply with the requirements of this title;
(4)
an artificial intelligence, algorithm, or other software tool does not replace the role of a health care provider in the determination process under § 15–10B–07 of this subtitle;
(5)
the use of an artificial intelligence, algorithm, or other software tool does not result in unfair discrimination;
(6)
an artificial intelligence, algorithm, or other software tool is fairly and equitably applied, including in accordance with any applicable regulations and guidance issued by the federal Department of Health and Human Services;
(7)
an artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the Commissioner;
(8)
written policies and procedures are included in the utilization plan submitted under § 15–10B–05 of this subtitle, including how an artificial intelligence, algorithm, or other software tool will be used and what oversight will be provided;
(9)
the performance, use, and outcomes of an artificial intelligence, algorithm, or other software tool are reviewed and revised, if necessary and at least on a quarterly basis, to maximize accuracy and reliability;
(10)
patient data is not used beyond its intended and stated purpose, consistent with the federal Health Insurance Portability and Accountability Act of 1996, as applicable; and
(11)
an artificial intelligence, algorithm, or other software tool does not directly or indirectly cause harm to an enrollee.
(d)
An artificial intelligence, algorithm, or other software tool may not deny, delay, or modify health care services.
Md. Code Ann., Ins. § 15-10B-06 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-06LinkCopy Citation
(a)
(1)
Except as otherwise provided in this subsection, a private review agent shall:
(i)
make all initial determinations on whether to authorize or certify a nonemergency course of treatment or health care service, including pharmaceutical services not submitted electronically, for a patient within 2 working days after receipt of the information necessary to make the determination;
(ii)
make all determinations on whether to authorize or certify an extended stay in a health care facility or additional health care services within 1 working day after receipt of the information necessary to make the determination;
(iii)
make all determinations to authorize or certify a request for additional visits or days of care submitted as part of an existing course of treatment or treatment plan within 1 working day after receipt of the information necessary to make the determination; and
(iv)
promptly notify the health care provider of the determination.
(2)
After receipt of the initial request for health care services and confirming through a complete review of information already submitted by the health care provider, if the private review agent determines that the private review agent does not have sufficient information to make a determination, the private review agent shall promptly, but not later than 3 calendar days after receipt of the initial request, inform the health care provider that additional information must be provided by specifying:
(i)
the information, including any lab or diagnostic test or other medical information, that must be submitted to complete the request; and
(ii)
the criteria and standards to support the need for additional information.
(b)
If a private review agent requires prior authorization for an emergency inpatient admission, or an admission for residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, emotional, or substance abuse disorder, the private review agent shall:
(1)
make all determinations on whether to authorize or certify an inpatient admission, or an admission for residential crisis services as defined in § 15–840 of this title, within 2 hours after receipt of the information necessary to make the determination;
(2)
if additional information is needed, promptly request the specific information needed, including any lab or diagnostic test or other medical information; and
(3)
promptly notify the health care provider of the determination.
(c)
(1)
For a step therapy exception request submitted electronically in accordance with a process established under § 15–142(f) of this title or a prior authorization request submitted electronically for pharmaceutical services, a private review agent shall make a determination:
(i)
in real time if:
(1)
no additional information is needed by the private review agent to process the request; and
(2)
the request meets the private review agent’s criteria for approval; or
(ii)
if a request is not approved in real time under item (i) of this paragraph, within 1 working day after the private review agent receives all of the information necessary to make the determination.
(2)
If additional information is needed to make a determination after confirming through a complete review of the information already submitted by the health care provider, the private review agent shall request the information promptly, but not later than 3 calendar days after receipt of the initial request, by specifying:
(i)
the information, including any lab or diagnostic test or other medical information, that must be submitted to complete the request; and
(ii)
the criteria and standards to support the need for the additional information.
(d)
(1)
(i)
Except as provided in subsections (g) and (h) of this section, a private review agent shall make initial determinations on whether to authorize or certify an emergency course of treatment or health care service for a member within 24 hours after the initial request after receipt of the information necessary to make the determination.
(ii)
If the private review agent determines that additional information is needed after confirming through a complete review of the information already submitted by the health care provider, the private review agent shall:
(1)
promptly request the specific information needed, including any lab or diagnostic test or other medical information; and
(2)
promptly, but not later than 2 hours after receipt of the information, notify the health care provider of an authorization or certification determination when made by the private review agent.
(2)
A private review agent shall initiate the expedited procedure for an emergency case if the patient or the patient’s representative requests or if the health care provider attests that the services are necessary to treat a condition or illness that, without immediate medical attention, would:
(i)
seriously jeopardize the life or health of the member or the member’s ability to regain maximum functions;
(ii)
cause the member to be in danger to self or others; or
(iii)
cause the member to continue using intoxicating substances in an imminently dangerous manner.
(e)
If a private review agent fails to make a determination within the time limits required under this section, the request shall be deemed approved.
(f)
(1)
If an initial determination is made by a private review agent not to authorize or certify a health care service and the health care provider believes the determination warrants an immediate reconsideration, a private review agent shall provide the health care provider the opportunity to speak with the physician that rendered the determination, by telephone on an expedited basis, within a period of time not to exceed 24 hours of the health care provider seeking the reconsideration.
(2)
If the physician is unable to immediately speak with the health care provider seeking the reconsideration, the physician shall provide the health care provider with the following contact information for the health care provider to use to contact the physician:
(i)
a direct telephone number that is not the general customer call number; or
(ii)
a monitored e–mail address that is dedicated to communication related to utilization review.
(g)
For emergency inpatient admissions, a private review agent may not render an adverse decision solely because the hospital did not notify the private review agent of the emergency admission within 24 hours or other prescribed period of time after that admission if the patient’s medical condition prevented the hospital from determining:
(1)
the patient’s insurance status; and
(2)
if applicable, the private review agent’s emergency admission notification requirements.
(h)
(1)
Subject to paragraph (2) of this subsection, a private review agent may not render an adverse decision as to an admission of a patient during the first 24 hours after admission when:
(i)
the admission is based on a determination that the patient is in imminent danger to self or others;
(ii)
the determination has been made by the patient’s physician or psychologist in conjunction with a member of the medical staff of the facility who has privileges to make the admission; and
(iii)
the hospital immediately notifies the private review agent of:
(1)
the admission of the patient; and
(2)
the reasons for the admission.
(2)
A private review agent may not render an adverse decision as to an admission of a patient to a hospital for up to 72 hours, as determined to be medically necessary by the patient’s treating physician, when:
(i)
the admission is an involuntary admission under §§ 10–615 and 10–617(a) of the Health – General Article; and
(ii)
the hospital immediately notifies the private review agent of:
(1)
the admission of the patient; and
(2)
the reasons for the admission.
(i)
(1)
A private review agent that requires a health care provider to submit a treatment plan in order for the private review agent to conduct utilization review of proposed or delivered services for the treatment of a mental illness, emotional disorder, or a substance abuse disorder:
(i)
shall accept:
(1)
the uniform treatment plan form adopted by the Commissioner under § 15–10B–03(d) of this subtitle as a properly submitted treatment plan form; or
(2)
if a service was provided in another state, a treatment plan form mandated by the state in which the service was provided; and
(ii)
may not impose any requirement to:
(1)
modify the uniform treatment plan form or its content; or
(2)
submit additional treatment plan forms.
(2)
A uniform treatment plan form submitted under the provisions of this subsection:
(i)
shall be properly completed by the health care provider; and
(ii)
may be submitted by electronic transfer.
Md. Code Ann., Ins. § 15-10B-07 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-07LinkCopy Citation
(a)
(1)
Except as provided in paragraphs (2) and (3) of this subsection, all adverse decisions shall be made by a licensed physician, or a panel of other appropriate health care service reviewers with at least one physician on the panel, who is:
(i)
board certified or eligible in the same specialty as the treatment under review; and
(ii)
knowledgeable about the requested health care service or treatment through actual clinical experience.
(2)
When the health care service under review is a mental health or substance abuse service, the adverse decision shall be made by a licensed physician, or a panel of other appropriate health care service reviewers with at least one licensed physician, selected by the private review agent who:
(i)
is board certified or eligible in the same specialty as the treatment under review; or
(ii)
is actively practicing or has demonstrated expertise in the substance abuse or mental health service or treatment under review.
(3)
When the health care service under review is a dental service, the adverse decision shall be made by a licensed dentist, or a panel of other appropriate health care service reviewers with at least one licensed dentist on the panel who is knowledgeable about the requested health care service or treatment through actual clinical experience.
(b)
All adverse decisions shall be made by a physician or a panel of other appropriate health care service reviewers who are not compensated by the private review agent in a manner that violates § 19–705.1 of the Health – General Article or that deters the delivery of medically appropriate care.
(c)
Except as provided in subsection (d) of this section, if a course of treatment has been preauthorized or approved for a patient, a private review agent may not retrospectively render an adverse decision regarding the preauthorized or approved services delivered to that patient.
(d)
A private review agent may retrospectively render an adverse decision regarding preauthorized or approved services delivered to a patient if:
(1)
the information submitted to the private review agent regarding the services to be delivered to the patient was fraudulent or intentionally misrepresentative;
(2)
critical information requested by the private review agent regarding services to be delivered to the patient was omitted such that the private review agent’s determination would have been different had the agent known the critical information; or
(3)
the planned course of treatment for the patient that was approved by the private review agent was not substantially followed by the provider.
(e)
If a course of treatment has been preauthorized or approved for a patient, a private review agent may not revise or modify the specific criteria or standards used for the utilization review to make an adverse decision regarding the services delivered to that patient.
Md. Code Ann., Ins. § 15-10B-08 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-08LinkCopy Citation
(a)
If a carrier delegates its internal grievance process to a private review agent, the private review agent shall establish an internal grievance process for its patients and health care providers acting on behalf of a patient.
(b)
A private review agent’s internal grievance process shall meet the same requirements established under §§ 15-10A-02 through 15-10A-05 of this title.
(c)
A private review agent may not charge a fee to a patient or health care provider for filing a grievance.
Md. Code Ann., Ins. § 15-10B-09 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-09LinkCopy Citation
(a)
In this section, “attending provider” means an obstetrician, pediatrician, or other physician or certified nurse midwife or pediatric nurse practitioner attending the mother or newborn child.
(b)
Except as provided in subsections (c) and (d) of this section, the criteria and standards used by a private review agent or health maintenance organization in performing utilization review of hospital services related to maternity and newborn care, including length of stay, shall be in accordance with the medical criteria outlined in the most current version of the “Guidelines for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.
(c)
Subject to the provisions of subsection (d) of this section, a private review agent or health maintenance organization performing utilization review of hospital services related to maternity and newborn care shall authorize a minimum coverage of:
(1)
48 hours of inpatient hospitalization care following an uncomplicated vaginal delivery; and
(2)
96 hours of inpatient hospitalization care following an uncomplicated cesarean section.
(d)
(1)
The private review agent or health maintenance organization may authorize a shorter length of stay than that provided in subsection (c) of this section if the mother, in consultation with her attending provider, decides that less time is needed for recovery.
(2)
For a mother and newborn child who have a hospital stay shorter in length than that provided under subsection (c) of this section, the private review agent or health maintenance organization performing utilization review shall authorize:
(i)
one home visit scheduled to occur within 24 hours after hospital discharge; and
(ii)
an additional home visit as may be prescribed by the attending provider.
(3)
For a mother and newborn child who remain in the hospital for at least the period of time provided under subsection (c) of this section, the private review agent or health maintenance organization performing utilization review shall authorize a home visit as may be prescribed by the attending provider.
(4)
A home visit under paragraph (2) or (3) of this subsection shall:
(i)
be provided in accordance with generally accepted standards of nursing practice for home care of a mother and newborn child;
(ii)
be provided by a registered nurse with at least 1 year of experience in maternal and child health nursing or in community health nursing with an emphasis on maternal and child health; and
(iii)
include any services required by the attending provider.
(e)
(1)
The private review agent or health maintenance organization may not require additional documentation from, require additional utilization review of, or otherwise provide financial disincentives for an attending provider who orders care for which coverage is required to be provided under this section, § 19-703 of the Health - General Article, or § 15-811 of this title.
(2)
The private review agent, hospital, or health maintenance organization may not deny, limit, or otherwise impair the participation of an attending provider under a contract or any privilege granted an attending provider who advocates more than 48 hours of inpatient hospital care following a complicated vaginal delivery or more than 96 hours of inpatient hospital care following a complicated cesarean section.
Md. Code Ann., Ins. § 15-10B-09.1 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-09.1LinkCopy Citation
A grievance decision shall be made based on the professional judgment of:
(1)
(i)
a licensed physician who is board certified or eligible in the same specialty as the treatment under review and knowledgeable about the requested health care service or treatment through actual clinical experience; or
(ii)
a panel of other appropriate health care service reviewers with at least one licensed physician on the panel who is board certified or eligible in the same specialty as the treatment under review and knowledgeable about the requested health care service or treatment through actual clinical experience;
(2)
when the grievance decision involves a dental service, a licensed dentist, or a panel of appropriate health care service reviewers with at least one dentist on the panel who is a licensed dentist, who shall consult with a dentist who is board certified or eligible in the same specialty as the service under review and knowledgeable about the requested health care service or treatment through actual clinical experience; or
(3)
when the grievance decision involves a mental health or substance abuse service:
(i)
a licensed physician who:
(1)
is board certified or eligible in the same specialty as the treatment under review; or
(2)
is actively practicing or has demonstrated expertise in the substance abuse or mental health service or treatment under review; or
(ii)
a panel of other appropriate health care service reviewers with at least one licensed physician, selected by the private review agent who:
(1)
is board certified or eligible in the same specialty as the treatment under review; or
(2)
is actively practicing or has demonstrated expertise in the substance abuse or mental health service or treatment under review.
Md. Code Ann., Ins. § 15-10B-10 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-10LinkCopy Citation
(a)
A certificate expires on the second anniversary of its effective date unless the certificate is renewed for a 2-year term as provided in this section.
(b)
Before the certificate expires, a certificate may be renewed for an additional 2-year term if the applicant:
(1)
otherwise is entitled to the certificate;
(2)
pays to the Commissioner the renewal fee set by the Commissioner through regulation; and
(3)
submits to the Commissioner:
(i)
a renewal application on the form that the Commissioner requires; and
(ii)
satisfactory evidence of compliance with any requirement under this subtitle for certificate renewal.
(c)
If the requirements of this section are met, the Commissioner shall renew a certificate.
Md. Code Ann., Ins. § 15-10B-11 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-11LinkCopy Citation
A private review agent may not:
(1)
violate any provision of this subtitle or any rule or regulation adopted under this subtitle;
(2)
fail to meet the requirements for certification under this subtitle;
(3)
obtain or attempt to obtain certification based on inaccurate information;
(4)
fraudulently or deceptively obtain or use a certificate;
(5)
fail to make available the services of sufficient numbers of registered nurses, medical records technicians, or similarly qualified persons supported and supervised by appropriate physicians to carry out its utilization review activities;
(6)
fail to meet any applicable regulations the Commissioner adopts under this subtitle relating to the qualifications of private review agents or the performance of utilization review;
(7)
fail to protect the confidentiality of medical records in accordance with applicable State and federal laws;
(8)
use criteria and standards to conduct utilization review unless the criteria and standards used by the private review agent are:
(i)
objective;
(ii)
clinically valid;
(iii)
compatible with established principles of health care; or
(iv)
flexible enough to allow deviations from norms when justified on a case-by-case basis; or
(9)
act as a private review agent without holding a certificate issued under this subtitle.
Md. Code Ann., Ins. § 15-10B-12 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-12LinkCopy Citation
(a)
(1)
A person who violates any provision of § 15-10B-11 of this subtitle is guilty of a misdemeanor and on conviction is subject to a penalty not exceeding $1,000.
(2)
Each day a violation is continued after the first conviction is a separate offense.
(b)
In addition to the provisions of subsection (a) of this section, if any person violates any provision of § 15-10B-11 of this subtitle, the Commissioner may:
(1)
deny, suspend, or revoke the certificate to do business as a private review agent;
(2)
issue an order to cease and desist from acting as a private review agent without holding a certificate issued under this subtitle;
(3)
require a private review agent to make restitution to a patient who has suffered actual economic damage because of the violation; and
(4)
impose an administrative penalty of up to $5,000 for each violation of any provision of this subtitle.
Md. Code Ann., Ins. § 15-10B-13 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-13LinkCopy Citation
Any person aggrieved by an order of the Commissioner under this subtitle has the right to a hearing and the right to appeal from the action of the Commissioner in accordance with §§ 2-210 through 2-215 of this article.
Md. Code Ann., Ins. § 15-10B-14 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-14LinkCopy Citation
The Commissioner may waive the requirements of this subtitle for a private review agent that operates solely under contract with the federal government for utilization review of patients eligible for hospital services under Title XVIII of the Social Security Act.
Md. Code Ann., Ins. § 15-10B-15 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-15LinkCopy Citation
The Commissioner shall periodically provide a list of private review agents issued certificates and the renewal date for those certificates to any person on request.
Md. Code Ann., Ins. § 15-10B-16 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-16LinkCopy Citation
The Commissioner may establish reporting requirements to:
(1)
evaluate the effectiveness of private review agents; and
(2)
determine if the utilization review programs are in compliance with the provisions of this section and applicable regulations.
Md. Code Ann., Ins. § 15-10B-17 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-17LinkCopy Citation
(a)
(1)
Except as provided in paragraph (2) of this subsection, this section does not apply to:
(i)
a private review agent referring an individual to a health care provider or facility that participates in a health maintenance organization;
(ii)
a preferred provider organization network of participating health care providers or facilities to which the individual would otherwise be referred as part of the individual’s membership or insurance contract; or
(iii)
an employee assistance program referring an individual to a network of participating health care providers or facilities in accordance with a contract with the individual’s employer or labor union to provide comprehensive mental health and substance abuse services.
(2)
A private review agent or any other individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may not approve or fail to approve a course of treatment based on whether the treatment is delivered by a provider who is a participating or nonparticipating provider in the preferred provider organization or employee assistance program network.
(b)
A private review agent or any individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may not:
(1)
refer a patient who has undergone utilization review by the private review agent to:
(i)
a health care facility in which the private review agent owns a significant beneficial interest; or
(ii)
the private review agent’s own health care practice;
(2)
pay or agree to pay any sum to, or accept or agree to accept any sum from, any person for bringing or referring a patient to the private review agent; or
(3)
provide for different insurance coverage or benefits based on receiving the service from a health care facility or health care provider in which the private review agent owns a significant beneficial interest.
(c)
A private review agent or any individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may refer a patient who has undergone utilization review by the private review agent to another health care provider regulated under the Health Occupations Article if:
(1)
(i)
the patient or provider requests the private review agent to provide the patient with the name of a health care provider appropriate to meet the health care needs of the patient; or
(ii)
the patient has no attending physician; and
(2)
the private review agent provides the patient with the names of at least two health care providers appropriate to meet the health care needs of the patient.
Md. Code Ann., Ins. § 15-10B-18 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-18LinkCopy Citation
(a)
A private review agent shall advise the Commissioner, in writing, of its intention to withdraw its certificate within 60 days of intention to cease operations as a private review agent.
(b)
A private review agent shall submit its certificate to the administration within 30 days after the date that the private review agent ceased operations.
Md. Code Ann., Ins. § 15-10B-19 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-19LinkCopy Citation
(a)
Whenever the Commissioner considers it advisable, the Commissioner shall examine the affairs, transactions, accounts, records, and assets of each private review agent at least once every 5 years.
(b)
The Commissioner shall examine the affairs, transactions, accounts, records, and assets of each private review agent that applies for a certificate of registration under § 15-10B-03 of this subtitle.
(c)
The examination shall be conducted in accordance with § 2-207 of this article.
(d)
The expense of the examination shall be paid in accordance with § 2-208 of this article.
(e)
The reports of the examination and investigation shall be issued in accordance with § 2-209 of this article.
Md. Code Ann., Ins. § 15-10B-20 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-20LinkCopy Citation
(a)
In addition to the requirements under § 15-10B-19 of this subtitle, the Commissioner shall conduct an examination of any pharmacy benefit manager registered as a private review agent to determine whether the pharmacy benefit manager is acting in compliance with this subtitle.
(b)
The examination shall be conducted:
(1)
in accordance with § 2-207 of this article; and
(2)
at least once every 3 years.
(c)
The expense of the examination shall be paid in accordance with § 2-208 of this article.
(d)
The reports of the examination shall be issued in accordance with § 2-209 of this article.
(e)
Within 30 days after the completion of a final report of an examination under this section, the Commissioner shall submit a copy of the report to the Senate Finance Committee and the House Health and Government Operations Committee in accordance with § 2–1257 of the State Government Article.
Md. Code Ann., Ins. § 15-10B-21 (2026)
Title 15. Health Insurance
Subtitle 10B. Private Review Agents
§ 15–10B-21LinkCopy Citation
(a)
The Commissioner may conduct an examination of a carrier that has issued a pattern of adverse decisions or grievance decisions for a claim or authorization request for services in, or related to services in, an emergency department.
(b)
A carrier examined under subsection (a) of this section shall produce all documents related to an adverse decision or grievance decision described under subsection (a) of this section, including documents or electronic documents in the possession of a private review agent acting on behalf of the carrier.
(c)
(1)
The Commissioner may have an adverse decision or grievance decision described under subsection (a) of this section reviewed by an independent review organization.
(2)
The costs of a review conducted under paragraph (1) of this subsection shall be paid by the carrier.
Subtitle 10C. Medical Directors
Md. Code Ann., Ins. § 15-10C-01 (2026)
Title 15. Health Insurance
Subtitle 10C. Medical Directors
§ 15–10C-01LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Board” means the State Board of Physicians established under Title 14 of the Health Occupations Article.
(c)
“Certificate” means a certificate issued by the Commissioner under this subtitle to act as a medical director.
(d)
“Department” means the Maryland Department of Health.
(e)
“Health maintenance organization” has the meaning stated in § 19–701 of the Health – General Article.
(f)
(1)
“Medical director” means a physician employed by or under contract with a health maintenance organization who is responsible for:
(i)
the establishment or maintenance of the policies and procedures at the health maintenance organization for:
(1)
quality assurance; and
(2)
utilization management;
(ii)
compliance with the quality assurance and utilization management policies and procedures of the health maintenance organization; and
(iii)
oversight of utilization review decisions of private review agents employed by or under contract with the health maintenance organization.
(2)
“Medical director” includes an associate medical director or an assistant medical director, as defined by the Commissioner by regulation.
Md. Code Ann., Ins. § 15-10C-02 (2026)
Title 15. Health Insurance
Subtitle 10C. Medical Directors
§ 15–10C-02LinkCopy Citation
The Commissioner, in consultation with the Department and the Board, shall establish and adopt by regulation standards for:
(1)
the certification of medical directors;
(2)
the renewal, suspension, and revocation of a certificate; and
(3)
the issuance of a temporary certificate.
Md. Code Ann., Ins. § 15-10C-03 (2026)
Title 15. Health Insurance
Subtitle 10C. Medical Directors
§ 15–10C-03LinkCopy Citation
(a)
To be certified as a medical director under this subtitle, an applicant shall:
(1)
submit an application to the Commissioner on the form required by the Commissioner; and
(2)
pay to the Commissioner an application fee of no more than $100 established by the Commissioner by regulation.
(b)
The application shall include:
(1)
a description of the applicant’s professional qualifications, including medical education information and, if appropriate, board certifications and licensure status;
(2)
the utilization management procedures and policies to be used by the health maintenance organization; and
(3)
certification by the medical director that the utilization management procedures and policies are:
(i)
objective;
(ii)
clinically valid;
(iii)
compatible with established principles of health care; and
(iv)
flexible enough to allow deviations from the norms when justified on a case by case basis.
(c)
The delegation by a medical director of any of the medical director’s responsibilities under this subtitle to an associate medical director or an assistant medical director does not prevent the medical director, regardless of the delegation, from being held responsible for any violation of this subtitle.
Md. Code Ann., Ins. § 15-10C-04 (2026)
Title 15. Health Insurance
Subtitle 10C. Medical Directors
§ 15–10C-04LinkCopy Citation
(a)
Subject to the hearing procedures in §§ 2-210 through 2-214 of this article, the Commissioner may suspend, revoke, or refuse to renew a certificate of a medical director if the Commissioner finds a pattern that the utilization management procedures and policies used by the medical director in making utilization review decisions or used by a private review agent employed by or under contract with the health maintenance organization over whose utilization review decisions the medical director has responsibility are not:
(1)
objective;
(2)
clinically valid;
(3)
compatible with established principles of health care; or
(4)
flexible enough to allow deviations from the norms when justified on a case by case basis.
(b)
The Commissioner may consult with an independent review organization or medical expert that meets the requirements of § 15-10A-05 of this title, the Department, the Board, or any other appropriate entity for purposes of taking an action described under subsection (a) of this section.
Subtitle 10D. Complaint Process for Coverage Decisions
Md. Code Ann., Ins. § 15-10D-01 (2026)
Title 15. Health Insurance
Subtitle 10D. Complaint Process for Coverage Decisions
§ 15–10D-01LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Appeal” means a protest filed by a member, a member’s representative, or a health care provider with a carrier under its internal appeal process regarding a coverage decision concerning a member.
(c)
“Appeal decision” means a final determination by a carrier that arises from an appeal filed with the carrier under its appeal process regarding a coverage decision concerning a member.
(d)
“Carrier” means a person that offers a health benefit plan and is:
(1)
an authorized insurer that provides health insurance in the State;
(2)
a nonprofit health service plan;
(3)
a health maintenance organization;
(4)
a dental plan organization;
(5)
a self–funded student health plan operated by an independent institution of higher education, as defined in § 10–101 of the Education Article, that provides health care to its students and their dependents; or
(6)
except for a managed care organization, as defined in Title 15, Subtitle 1 of the Health – General Article, any other person that offers a health benefit plan subject to regulation by the State.
(e)
“Complaint” means a protest filed with the Commissioner involving a coverage decision other than that which is covered by Subtitle 10A of this title.
(f)
(1)
“Coverage decision” means:
(i)
an initial determination by a carrier or a representative of the carrier that results in noncoverage of a health care service;
(ii)
a determination by a carrier that an individual is not eligible for coverage under the carrier’s health benefit plan; or
(iii)
any determination by a carrier that results in the rescission of an individual’s coverage under a health benefit plan.
(2)
“Coverage decision” includes nonpayment of all or any part of a claim.
(3)
“Coverage decision” does not include:
(i)
an adverse decision as defined in § 15–10A–01(b) of this title; or
(ii)
a pharmacy inquiry.
(g)
“Designee of the Commissioner” means any person to whom the Commissioner has delegated the authority to review and decide complaints filed under this subtitle, including an administrative law judge to whom the authority to conduct a hearing has been delegated for recommended or final decision.
(h)
(1)
“Health benefit plan” means:
(i)
a hospital or medical policy or contract, including a policy or contract issued under a multiple employer trust or association;
(ii)
a hospital or medical policy or contract issued by a nonprofit health service plan;
(iii)
a health maintenance organization contract; or
(iv)
a dental plan organization contract.
(2)
“Health benefit plan” does not include one or more, or any combination of the following:
(i)
long–term care insurance;
(ii)
disability insurance;
(iii)
accidental travel and accidental death and dismemberment insurance;
(iv)
credit health insurance;
(v)
a health benefit plan issued by a managed care organization, as defined in Title 15, Subtitle 1 of the Health – General Article;
(vi)
disease–specific insurance; or
(vii)
fixed indemnity insurance.
(i)
“Health care provider” means:
(1)
an individual who is licensed under the Health Occupations Article to provide health care services in the ordinary course of business or practice of a profession and is a treating provider of the member; or
(2)
a hospital, as defined in § 19–301 of the Health – General Article.
(j)
“Health care service” means a health or medical care procedure or service rendered by a health care provider that:
(1)
provides testing, diagnosis, or treatment of a human disease or dysfunction; or
(2)
dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction.
(k)
(1)
“Member” means:
(i)
a person entitled to health care services under a policy, plan, or contract issued or delivered in the State by a carrier; or
(ii)
with regard to an individual who is determined by a carrier not to be eligible for a health benefit plan, an individual who has applied for coverage under a health benefit plan.
(2)
“Member” includes:
(i)
a subscriber; and
(ii)
unless preempted by federal law, a Medicare recipient.
(3)
“Member” does not include a Medicaid recipient.
(l)
“Member’s representative” means an individual who has been authorized by the member to file an appeal or a complaint on behalf of the member.
(m)
“Pharmacy benefits manager” has the meaning stated in § 15–1601 of this title.
(n)
“Pharmacy inquiry” means an inquiry submitted by a pharmacist or pharmacy on behalf of a member to a carrier or a pharmacy benefits manager at the point of sale about the scope of pharmacy coverage, pharmacy benefit design, or formulary under a health benefit plan.
Md. Code Ann., Ins. § 15-10D-02 (2026)
Title 15. Health Insurance
Subtitle 10D. Complaint Process for Coverage Decisions
§ 15–10D-02LinkCopy Citation
(a)
(1)
Each carrier shall establish an internal appeal process for use by its members, its members’ representatives, and health care providers to dispute coverage decisions made by the carrier.
(2)
The carrier may use the internal grievance process established under Subtitle 10A of this title to comply with the requirement of paragraph (1) of this subsection.
(b)
A carrier under this section shall render a final decision in writing to a member, a member’s representative, and a health care provider acting on behalf of the member within 60 working days after the date on which the appeal is filed.
(c)
Except as provided in subsection (d) of this section, the carrier’s internal appeal process shall be exhausted prior to filing a complaint with the Commissioner under this subtitle.
(d)
A member, a member’s representative, or a health care provider filing a complaint on behalf of a member may file a complaint with the Commissioner without first filing an appeal with a carrier only if the coverage decision involves an urgent medical condition, as defined by regulation adopted by the Commissioner, for which care has not been rendered.
(e)
(1)
Within 30 calendar days after a coverage decision has been made, a carrier shall send a written notice of the coverage decision to the member and the member’s representative, if any, and, in the case of a health maintenance organization, the treating health care provider.
(2)
Notice of the coverage decision required to be sent under paragraph (1) of this subsection shall:
(i)
state in detail in clear, understandable language, the specific factual bases for the carrier’s decision; and
(ii)
include the following information:
(1)
that the member, the member’s representative, or a health care provider acting on behalf of the member has a right to file an appeal with the carrier;
(2)
that the member, the member’s representative, or a health care provider acting on behalf of the member may file a complaint with the Commissioner without first filing an appeal, if the coverage decision involves an urgent medical condition for which care has not been rendered;
(3)
the Commissioner’s address, telephone number, and facsimile number;
(4)
that the Health Advocacy Unit is available to assist the member or the member’s representative in both mediating and filing an appeal under the carrier’s internal appeal process; and
(5)
the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.
(f)
(1)
Within 30 calendar days after the appeal decision has been made, each carrier shall send to the member, the member’s representative, and the health care provider acting on behalf of the member a written notice of the appeal decision.
(2)
Notice of the appeal decision required to be sent under paragraph (1) of this subsection shall:
(i)
state in detail in clear, understandable language the specific factual bases for the carrier’s decision; and
(ii)
include the following information:
(1)
that the member, the member’s representative, or a health care provider acting on behalf of the member has a right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s appeal decision;
(2)
the Commissioner’s address, telephone number, and facsimile number;
(3)
a statement that the Health Advocacy Unit is available to assist the member in filing a complaint with the Commissioner; and
(4)
the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.
(g)
The Commissioner may request the member that filed the complaint or a legally authorized designee of the member to sign a consent form authorizing the release of the member’s medical records to the Commissioner or the Commissioner’s designee that are needed in order for the Commissioner to make a final decision on the complaint.
(h)
(1)
A carrier shall have the burden of persuasion that its coverage decision or appeal decision, as applicable, is correct:
(i)
during the review of a complaint by the Commissioner or a designee of the Commissioner; and
(ii)
in any hearing held in accordance with Title 10, Subtitle 2 of the State Government Article to contest a final decision of the Commissioner made and issued under this subtitle.
(2)
As part of the review of a complaint, the Commissioner or a designee of the Commissioner may consider all of the facts of the case and any other evidence that the Commissioner or designee of the Commissioner considers appropriate.
(i)
The Commissioner shall:
(1)
make and issue in writing a final decision on all complaints filed with the Commissioner under this subtitle that are within the Commissioner’s jurisdiction; and
(2)
provide notice in writing to all parties to a complaint of the opportunity and time period for requesting a hearing to be held in accordance with Title 10, Subtitle 2 of the State Government Article to contest a final decision of the Commissioner made and issued under this subtitle.
Md. Code Ann., Ins. § 15-10D-03 (2026)
Title 15. Health Insurance
Subtitle 10D. Complaint Process for Coverage Decisions
§ 15–10D-03LinkCopy Citation
(a)
It is a violation of this subtitle for a carrier to fail to fulfill the carrier’s obligations to provide or reimburse for health care services specified in the carrier’s policies or contracts with members.
(b)
If, in rendering a coverage decision or appeal decision, a carrier fails to fulfill the carrier’s policies or contracts with members, the Commissioner may:
(1)
issue an administrative order that requires the carrier to:
(i)
cease inappropriate conduct or practices by the carrier or any of the personnel employed or associated with the carrier;
(ii)
fulfill the carrier’s contractual obligations;
(iii)
provide a health care service or payment that has been denied improperly; or
(iv)
take appropriate steps to restore the carrier’s ability to provide a health care service or payment that is provided under a contract; or
(2)
impose any penalty or fine or take any action as authorized:
(i)
for an insurer, nonprofit health service plan, or dental plan organization, under this article; or
(ii)
for a health maintenance organization, under the Health - General Article or under this article.
Md. Code Ann., Ins. § 15-10D-04 (2026)
Title 15. Health Insurance
Subtitle 10D. Complaint Process for Coverage Decisions
§ 15–10D-04LinkCopy Citation
The Commissioner may adopt any necessary regulations to carry out the provisions of this subtitle.
Md. Code Ann., Ins. § 15-10D-05 (2026)
Title 15. Health Insurance
Subtitle 10D. Complaint Process for Coverage Decisions
§ 15–10D-05LinkCopy Citation
A carrier shall provide the notices required to be provided to members under this subtitle in a culturally and linguistically appropriate manner as described in the Affordable Care Act.
Subtitle 11. Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans
Md. Code Ann., Ins. § 15-1102 (2026)
Title 15. Health Insurance
Subtitle 11. Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans
§ 15–1102LinkCopy Citation
(a)
In this section, “employee” includes:
(1)
an officer, manager, or retired employee of an employer;
(2)
a sole proprietor if the employer is a sole proprietorship; and
(3)
a partner if the employer is a partnership.
(b)
Health insurance on a franchise plan is the form of health insurance:
(1)
that is issued to:
(i)
three or more employees of a corporation, partnership, sole proprietorship, or governmental corporation, agency, or department; or
(ii)
ten or more members, employees, or employees of members of a labor union, or trade, professional, or other association, that is organized in good faith for purposes other than obtaining insurance, has a constitution or bylaws, and has had an active existence for at least 2 years;
(2)
under which the individuals insured, with or without their dependents, are issued the same form of an individual policy that varies only as to amounts and kinds of coverage applied for; and
(3)
under which the premiums on the individual policies may be paid to the insurer periodically by:
(i)
the employer, with or without payroll deductions;
(ii)
the labor union or association for its members; or
(iii)
a designated person acting on behalf of the employer, labor union, or association.
Md. Code Ann., Ins. § 15-1103 (2026)
Title 15. Health Insurance
Subtitle 11. Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans
§ 15–1103LinkCopy Citation
(a)
In this section, “transportation ticket policy” means a ticket policy of health insurance that:
(1)
has as its dominant feature the protection of the insured from a transportation hazard; and
(2)
is sold at transportation stations, ticket offices, or travel bureaus by:
(i)
vending machines;
(ii)
employees of railroads, steam lines, airlines, or other organizations engaged in transporting individuals on common carriers;
(iii)
individuals or employees of persons engaged in selling transportation on common carriers; or
(iv)
other qualified agents.
(b)
A transportation ticket policy may not be issued or delivered in the State unless it conforms to the requirements and provisions of §§ 15-102, 15-201, 15-202, 15-203, 15-205, and 15-207 through 15-226 of this title, subject to § 15-202(c) of this title that relates to inapplicable or inconsistent provisions.
Md. Code Ann., Ins. § 15-1104 (2026)
Title 15. Health Insurance
Subtitle 11. Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans
§ 15–1104LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Employer sponsored health benefit plan” means any plan, fund, or program that:
(i)
is established or maintained by an employer under the Employee Retirement Income Security Act of 1974;
(ii)
offers coverage for health benefits; and
(iii)
is treated by the employer or any eligible employee or dependent as part of a plan, fund, or program under the United States Internal Revenue Code, 26 U.S.C. § 106, § 125, or § 162.
(3)
“Group health insurance” has the meaning stated in § 15–302 of this title.
(4)
“Limited benefit group health insurance contract” means a group health insurance contract that provides health insurance benefits, but is not required to provide all the benefits required under Subtitles 7 and 8 of this title.
(5)
“Special eligible employee” means an employee who:
(i)
is eligible for health coverage under the terms of an employer sponsored health benefit plan;
(ii)
works:
(1)
on a temporary or substitute basis; or
(2)
less than 30 hours in a normal workweek; and
(iii)
is not eligible for coverage under any group health insurance contract, nonprofit health service plan contract, or health maintenance organization contract issued to the employee’s employer because the employee meets the criteria of item (ii) of this paragraph.
(b)
A limited benefit group health insurance contract may be issued only by an insurer or nonprofit health service plan to an employer if the limited group health insurance contract is issued to provide health coverage only for:
(1)
special eligible employees; or
(2)
special eligible employees and their dependents.
(c)
An insurer or nonprofit health service plan that sells a limited benefit group health insurance contract, as a condition of sale, may require the employer to:
(1)
collect payment for premiums due under the limited benefit group health insurance contract through payroll deduction;
(2)
contribute to the premium payments applicable to the coverage of a special eligible employee; and
(3)
offer coverage to any dependent of a special eligible employee.
(d)
A limited benefit group health insurance contract shall comply with:
(1)
this title, except Subtitles 7 and 8 of this title; and
(2)
notwithstanding item (1) of this subsection, §§ 15–802, 15–812, 15–815, 15–830, 15–831, 15–832, and 15–833 of this title.
(e)
An insurer or nonprofit health service plan shall disclose in the group certificate and in enrollment material provided to each special eligible employee that the limited benefit group health insurance contract does not provide comprehensive health coverage.
Md. Code Ann., Ins. § 15-1106 (2026)
Title 15. Health Insurance
Subtitle 11. Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans
§ 15–1106LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Carrier” means:
(i)
an insurer;
(ii)
a nonprofit health service plan; or
(iii)
a health maintenance organization.
(3)
“Evidence of individual insurability” has the meaning stated in § 15–1105 of this subtitle.
(4)
“Health benefit plan” has the meaning stated in § 15–1301 of this title.
(b)
If a carrier conditions coverage for a health benefit plan on evidence of individual insurability, the carrier may not rescind a contract or a certificate on the basis of written information submitted on or with, or omitted from, an application for the health benefit plan unless the carrier completed medical underwriting and resolved all reasonable medical questions related to the written information submitted on or with, or omitted from, the application before issuing the health benefit plan.
(c)
The carrier shall have the burden of persuasion that its rescission of a health benefit plan complies with subsection (b) of this section.
Subtitle 12. Maryland Health Insurance Reform Act
Md. Code Ann., Ins. § 15-1201 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1201LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Board” means the Board of Directors of the Pool established under § 15–1216 of this subtitle.
(c)
“Carrier” means a person that:
(1)
offers health benefit plans in the State covering eligible employees of small employers; and
(2)
is:
(i)
an authorized insurer that provides health insurance in the State;
(ii)
a nonprofit health service plan that is licensed to operate in the State;
(iii)
a health maintenance organization that is licensed to operate in the State; or
(iv)
any other person or organization that provides health benefit plans subject to State insurance regulation.
(d)
“Commission” means the Maryland Health Care Commission established under Title 19, Subtitle 1 of the Health – General Article.
(e)
“Coverage level” has the meaning stated in § 31–101 of this article.
(f)
(1)
“Eligible employee” means an employee who is offered coverage under a health benefit plan by a small employer.
(2)
“Eligible employee”, at the option of the small employer, may include:
(i)
only full–time employees; or
(ii)
full–time employees and part–time employees.
(g)
“Employee” means an individual who is employed by a small employer.
(h)
(1)
“Full–time employee” means, with respect to a calendar month, an employee of a small employer who works, on average, at least 30 hours per week.
(2)
“Full–time employee” does not include a seasonal employee as defined in federal law.
(i)
(1)
“Health benefit plan” means:
(i)
a policy or certificate for hospital or medical benefits issued by an insurer;
(ii)
a nonprofit health service plan contract; or
(iii)
a health maintenance organization subscriber or group master contract.
(2)
“Health benefit plan” includes a policy or certificate for hospital or medical benefits that covers residents of this State who are eligible employees and that is issued through:
(i)
a multiple employer trust or association located in this State or another state; or
(ii)
a professional employer organization, coemployer, or other organization located in this State or another state that engages in employee leasing.
(3)
“Health benefit plan” does not include:
(i)
accident–only insurance;
(ii)
credit health insurance;
(iii)
disability income insurance;
(iv)
coverage issued as a supplement to liability insurance;
(v)
workers’ compensation or similar insurance;
(vi)
automobile medical payment insurance;
(vii)
the following benefits, if the benefits are provided under a separate policy, certificate, or contract, or are not otherwise an integral part of a small employer health benefit plan:
(1)
dental benefits;
(2)
vision benefits; or
(3)
long–term care insurance as defined in § 18–101 of this article;
(viii)
disease–specific insurance if:
(1)
the benefits are provided under a separate policy, certificate, or contract;
(2)
there is no coordination between the provision of the benefits and an exclusion of benefits under any group health plan maintained by the same employer; and
(3)
the benefits are paid with respect to an event, without regard to whether benefits are provided with respect to the event under any group health plan maintained by the same employer;
(ix)
hospital indemnity or other fixed indemnity insurance if:
(1)
the benefits are provided under a separate policy, certificate, or contract;
(2)
there is no coordination between the provision of the benefits and an exclusion of benefits under any group health plan maintained by the same employer;
(3)
the benefits are paid with respect to an event, without regard to whether benefits are provided with respect to the event under any group health plan maintained by the same employer; and
(4)
the benefits are payable in a fixed dollar amount per period of time, regardless of the amount of expenses incurred; or
(x)
the following supplemental benefits, if the benefits are provided under a separate policy, certificate, or contract:
(1)
a Medicare supplement policy as defined in § 15–901 of this title;
(2)
coverage supplemental to the coverage provided under Chapter 55, Title 10 of the United States Code; and
(3)
similar supplemental coverage provided to coverage under a group health plan if the coverage qualifies for the exception described in 45 C.F.R. § 146.145(b)(5)(i)(C).
(j)
“Health care practitioner” has the meaning stated in § 1–301 of the Health Occupations Article.
(k)
“Health status–related factor” means a factor related to:
(1)
health status;
(2)
medical condition;
(3)
claims experience;
(4)
receipt of health care;
(5)
medical history;
(6)
genetic information;
(7)
evidence of insurability including conditions arising out of acts of domestic violence; or
(8)
disability.
(l)
“Late enrollee” means an eligible employee or dependent who requests enrollment in a health benefit plan after the initial enrollment period provided under the health benefit plan.
(m)
“Minimum essential coverage” has the meaning stated in 45 C.F.R. § 155.20.
(n)
“Part–time employee” means an employee of a small employer who:
(1)
has a normal workweek of at least 17.5 hours; and
(2)
is not a full–time employee.
(o)
“Plan year” means a calendar year or other consecutive 12–month period during which a health benefit plan provides coverage for health care services.
(p)
“Pool” means the Maryland Small Employer Health Reinsurance Pool established under this subtitle.
(q)
“Preexisting condition” means:
(1)
a condition existing during a specified period immediately preceding the effective date of coverage, that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment; or
(2)
a condition for which medical advice, diagnosis, care, or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.
(r)
“Preexisting condition provision” means a provision in a health benefit plan that denies, excludes, or limits benefits for an enrollee for expenses or services related to a preexisting condition.
(s)
“Qualified employer” has the meaning stated in § 31–101 of this article.
(t)
“Qualified health plan” has the meaning stated in § 31–101 of this article.
(u)
“Reinsuring carrier” means a carrier that participates in the Pool.
(v)
“Risk–assuming carrier” means a carrier that does not participate in the Pool.
(w)
“SHOP Exchange” has the meaning stated in § 31–101 of this article.
(x)
“Small employer” has the meaning stated in § 31–101 of this article.
(y)
“Special enrollment period” means a period during which a group health plan shall permit certain individuals who are eligible for coverage, but not enrolled, to enroll for coverage under the terms of the group health benefit plan.
(z)
“Standard Plan” means the Comprehensive Standard Health Benefit Plan adopted by the Commission in accordance with § 15–1207 of this subtitle and Title 19, Subtitle 1 of the Health – General Article.
(aa)
“Wellness benefit” means a benefit that:
(1)
includes a bona fide wellness program as defined in § 15–509 of this title; and
(2)
complies with regulations adopted by the Commission.
(bb)
(1)
“Wellness program” means a program or activity that:
(i)
is designed to improve health status and reduce health care costs; and
(ii)
complies with guidelines developed by the Commission.
(2)
“Wellness program” includes programs and activities for:
(i)
smoking cessation;
(ii)
reduction of alcohol misuse;
(iii)
weight reduction;
(iv)
nutrition education; and
(v)
automobile and motorcycle safety.
Md. Code Ann., Ins. § 15-1202 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1202LinkCopy Citation
(a)
This subtitle applies only to a health benefit plan that:
(1)
covers eligible employees of small employers in the State; and
(2)
is issued or renewed on or after July 1, 1994, if:
(i)
any part of the premium or benefits is paid by or on behalf of the small employer;
(ii)
any eligible employee or dependent is reimbursed, through wage adjustments or otherwise, by or on behalf of the small employer for any part of the premium;
(iii)
the health benefit plan is treated by the employer or any eligible employee or dependent as part of a plan or program under the United States Internal Revenue Code, 26 U.S.C. § 106, § 125, or § 162; or
(iv)
the small employer allows eligible employees to pay for the health benefit plan through payroll deductions.
(b)
This subtitle applies to any health benefit plan offered by an association, a professional employer organization, or any other entity, including a plan issued under the laws of another state, if the health benefit plan covers eligible employees of one or more small employers and meets the requirements of subsection (a) of this section.
Md. Code Ann., Ins. § 15-1204 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1204LinkCopy Citation
(a)
This section applies to a carrier with respect to any health benefit plan that is a grandfathered health plan, as defined in § 1251 of the Affordable Care Act.
(b)
In addition to any other requirement under this article, a carrier shall:
(1)
have demonstrated the capacity to administer the health benefit plan, including adequate numbers and types of administrative personnel;
(2)
have a satisfactory grievance procedure and ability to respond to enrollees’ calls, questions, and complaints;
(3)
provide, in the case of individuals covered under more than one health benefit plan, for coordination of coverage under all of those health benefit plans in an equitable manner; and
(4)
design policies to help ensure adequate access to providers of health care.
(c)
A person may not offer a health benefit plan in the State unless the person offers at least the Standard Plan.
(d)
A carrier may not offer a health benefit plan that has fewer benefits than those in the Standard Plan.
(e)
A carrier may offer benefits in addition to those in the Standard Plan if:
(1)
the additional benefits:
(i)
are offered and priced separately from benefits specified in accordance with § 15–1207 of this subtitle; and
(ii)
do not have the effect of duplicating any of those benefits; and
(2)
the carrier:
(i)
clearly distinguishes the Standard Plan from other offerings of the carrier;
(ii)
indicates the Standard Plan is the only plan required by State law; and
(iii)
specifies that all enhancements to the Standard Plan are not required by State law.
(f)
Notwithstanding subsection (c) of this section, a health maintenance organization may provide a point of service delivery system as an additional benefit through another carrier regardless of whether the other carrier also offers the Standard Plan.
(g)
A carrier may offer coverage for dental care and services as an additional benefit.
(h)
(1)
In this subsection, “prominent carrier” means a carrier that insures at least 10% of the total lives insured in the small group market.
(2)
(i)
A prominent carrier shall offer a wellness benefit for a health benefit plan offered under this subtitle.
(ii)
A carrier that is not a prominent carrier may offer a wellness benefit for a health benefit plan offered under this subtitle.
(3)
A carrier may not condition the sale of a wellness benefit to a small employer on participation of the eligible employees of the small employer in wellness programs or activities.
Md. Code Ann., Ins. § 15-1204.1 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1204.1LinkCopy Citation
(a)
This section applies to a carrier with respect to any health benefit plan that:
(1)
is not a grandfathered health plan, as defined in § 1251 of the Affordable Care Act; and
(2)
is issued, delivered, or renewed in the State on or after January 1, 2014.
(b)
(1)
Except as provided in this subsection and § 31–110(f) of this article, a carrier may not offer health benefit plans to small employers in the State unless the carrier also offers qualified health plans, as defined in § 31–101 of this article, in the Small Business Health Options Program of the Maryland Health Benefit Exchange in compliance with the requirements of Title 31 of this article.
(2)
A carrier is exempt from the requirement in paragraph (1) of this subsection if:
(i)
the reported total aggregate annual earned premium from all health benefit plans offered to small employers in the State for the carrier and any other carriers in the same insurance holding company system, as defined in § 7–101 of this article, is less than $20,000,000;
(ii)
the Commissioner determines that the carrier complies with the procedures established under paragraph (3) of this subsection; and
(iii)
when the carrier ceases to meet the requirements for the exemption, the carrier provides to the Commissioner immediate notice and its plan for complying with the requirement in paragraph (1) of this subsection.
(3)
The Commissioner shall establish procedures for a carrier to submit evidence each year that the carrier meets the requirements necessary to qualify for an exemption under paragraph (2) of this subsection.
(4)
Notwithstanding the exemption provided in paragraph (2) of this subsection, the Commissioner, in consultation with the Maryland Health Benefit Exchange:
(i)
may assess the impact of the exemption provided in paragraph (2) of this subsection and, based on that assessment, alter the limit on the amount of annual premiums that may not be exceeded to qualify for the exemption; and
(ii)
shall make any change in the exemption requirement by regulation.
Md. Code Ann., Ins. § 15-1205 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1205LinkCopy Citation
(a)
(1)
This subsection applies to a carrier with respect to any health benefit plan that is a grandfathered health plan, as defined in § 1251 of the Affordable Care Act.
(2)
In establishing a community rate for a health benefit plan, a carrier shall use a rating methodology that is based on the experience of all risks covered by that health benefit plan without regard to any factor not specifically authorized under this subsection or subsection (g) of this section.
(3)
A carrier may adjust the community rate only for:
(i)
age;
(ii)
geography based on the following contiguous areas of the State:
(1)
the Baltimore metropolitan area;
(2)
the District of Columbia metropolitan area;
(3)
Western Maryland; and
(4)
Eastern and Southern Maryland; and
(iii)
health status, as provided in subsection (g) of this section.
(4)
Rates for a health benefit plan may vary based on family composition as approved by the Commissioner.
(5)
(i)
Subject to subparagraph (ii) of this paragraph, after applying the risk adjustment factors under paragraph (3) of this subsection, a carrier may offer a discount not to exceed 20% to a small employer for participation in a wellness program.
(ii)
A discount offered under subparagraph (i) of this paragraph shall be:
(1)
applied to reduce the rate otherwise payable by the small employer;
(2)
actuarially justified;
(3)
offered uniformly to all small employers; and
(4)
approved by the Commissioner.
(b)
(1)
This subsection applies to a carrier with respect to any health benefit plan that:
(i)
is not a grandfathered health plan, as defined in § 1251 of the Affordable Care Act; and
(ii)
is issued, delivered, or renewed in the State on or after January 1, 2014.
(2)
In establishing a premium rate for a health benefit plan, a carrier shall use a rating methodology that is based on the experience of all risks covered by that health benefit plan without regard to any factor not specifically authorized under this subsection.
(3)
In accordance with § 2701(a) of the Affordable Care Act, a premium rate may vary only by:
(i)
whether the health benefit plan covers an individual or a family;
(ii)
rating area;
(iii)
age, except that a rate may not vary by more than 3 to 1 for adults; and
(iv)
tobacco use, except that a rate may not vary by more than 1.5 to 1.
(4)
A rate may not vary by any factor that is not specified in paragraph (3) of this subsection.
(c)
(1)
A carrier shall apply all risk adjustment factors under subsections (a) and (g) of this section consistently with respect to all health benefit plans that are:
(i)
issued, delivered, or renewed in the State; and
(ii)
grandfathered health plans, as defined in § 1251 of the Affordable Care Act.
(2)
A carrier shall apply all risk adjustment factors under subsection (b) of this section consistently with respect to all health benefit plans that are:
(i)
issued, delivered, or renewed in the State; and
(ii)
not grandfathered health plans, as defined in § 1251 of the Affordable Care Act.
(d)
(1)
This subsection applies to a carrier with respect to any health benefit plan that is a grandfathered health plan.
(2)
Based on the adjustments allowed under subsection (a)(3)(i) and (ii) of this section, a carrier may charge a rate that is 50% above or 50% below the community rate.
(3)
On or before October 1, 2007, the Commission shall adopt regulations that require carriers to collect and report to the Commission data on participation, by rate band, in health benefit plans issued, delivered, or renewed under this subtitle.
(e)
(1)
A carrier shall base its rating methods and practices on commonly accepted actuarial assumptions and sound actuarial principles.
(2)
A carrier that is a health maintenance organization and that includes a subrogation provision in its contract as authorized under § 19–713.1(d) of the Health – General Article shall:
(i)
use in its rating methodology an adjustment that reflects the subrogation; and
(ii)
identify in its rate filing with the Administration, and annually in a form approved by the Commissioner, all amounts recovered through subrogation.
(f)
(1)
This subsection applies to a carrier with respect to any health benefit plan that is a grandfathered health plan, as defined in § 1251 of the Affordable Care Act.
(2)
A carrier may offer an administrative discount to a small employer if the small employer elects to purchase, for its employees, an annuity, dental insurance, disability insurance, life insurance, long–term care insurance, vision insurance, or, with the approval of the Commissioner, any other insurance sold by the carrier.
(3)
The administrative discount shall be offered under the same terms and conditions for all qualifying small employers.
(g)
(1)
A carrier may adjust the community rate for a health benefit plan that is a grandfathered health plan, as defined in § 1251 of the Affordable Care Act, for health status only if a small employer has not offered a health benefit plan issued under this subtitle to its employees in the 12 months prior to the initial enrollment of the small employer in the health benefit plan.
(2)
(i)
Based on the adjustment allowed under paragraph (1) of this subsection, in addition to the adjustments allowed under subsection (d)(1) of this section, a carrier may charge:
(1)
in the first year of enrollment, a rate that is 10% above or below the community rate;
(2)
in the second year of enrollment, a rate that is 5% above or below the community rate; and
(3)
in the third year of enrollment, a rate that is 2% above or below the community rate.
(ii)
A carrier may not make any adjustment for health status in the community rate of a health benefit plan issued under this subtitle after the third year of enrollment of a small employer in the health benefit plan.
(3)
For a health benefit plan that is a grandfathered health plan, as defined in § 1251 of the Affordable Care Act, a carrier may use health statements, in a form approved by the Commissioner, and health screenings to establish an adjustment to the community rate for health status as provided in this subsection.
(4)
A carrier may not limit coverage offered by the carrier, or refuse to issue a health benefit plan to any small employer that meets the requirements of this subtitle, based on a health status–related factor.
(5)
It is an unfair trade practice for a carrier knowingly to provide coverage to a small employer that discriminates against an employee or applicant for employment, based on the health status of the employee or applicant or a dependent of the employee or applicant, with respect to participation in a health benefit plan sponsored by the small employer.
(h)
A carrier shall set premium rates for the entire plan year for each small employer.
Md. Code Ann., Ins. § 15-1206 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1206LinkCopy Citation
(a)
(1)
A carrier may not arbitrarily transfer a small employer involuntarily into or out of a health benefit plan.
(2)
A carrier may not offer to transfer a small employer into or out of a health benefit plan unless the offer to transfer is made to all small employers with similar risk adjustment factors.
(b)
A carrier shall make a reasonable disclosure in its solicitation and sales materials of:
(1)
the provisions that relate to the carrier’s right to change premium rates, including any factors that may affect the changes in premium rates;
(2)
the provisions that relate to renewability of policies and contracts;
(3)
the provisions that relate to preexisting conditions; and
(4)
the provisions of § 15–1209 of this subtitle that require an employer to make dependent coverage available to eligible employees but do not require the employer to make a contribution to the premium payments for that dependent coverage.
(c)
(1)
Subject to the approval of the Commissioner and as provided under this subsection and § 15–1209(d) of this subtitle, a carrier may impose reasonable minimum participation requirements.
(2)
A carrier may not impose a requirement for minimum participation by the eligible employees of a small employer that is greater than 75%.
(3)
In applying a minimum participation requirement to determine whether the applicable percentage of participation is met, a carrier may not consider as eligible employees:
(i)
those who have group spousal coverage under a public or private plan of health insurance or another employer’s health benefit arrangement, including Medicare, Medicaid, and CHAMPUS, that provides benefits similar to or exceeding the benefits provided under a bronze level health plan as described in 45 C.F.R. § 156.140; or
(ii)
employees who are under the age of 26 years who are covered under their parent’s health benefit plan.
(4)
A carrier may not impose a minimum participation requirement for a small employer group if any member of the group participates in a medical savings account.
(5)
A carrier may not impose a minimum participation requirement for a qualified employer if the qualified employer designates a coverage level within which its employees may choose any qualified health plan in the SHOP Exchange, as provided for in § 31–111(c)(1) of this article.
(6)
A carrier may not impose a minimum participation requirement for a small employer group if the small employer group applies for coverage during the period that begins on November 15 and extends through December 15 of any year.
(d)
(1)
On or before March 15 of each year, each carrier shall file an actuarial certification with the Commissioner.
(2)
The actuarial certification shall be written in a form that the Commissioner approves, by a member of the American Academy of Actuaries or another person acceptable to the Commissioner and shall state that the carrier is in compliance with this subtitle and has followed the rating practices imposed under § 15–1205 of this subtitle.
(3)
The actuarial certification shall be based on an examination that includes a review of appropriate records and actuarial assumptions and methods used by the carrier.
(e)
(1)
To indicate compliance with subsections (b) and (c)(1) of this section and § 15–1205(e) of this subtitle, a carrier shall maintain information and documentation that is satisfactory to the Commissioner.
(2)
A carrier shall:
(i)
retain all information and documentation required under this subtitle at its principal place of business for a period of 5 years; and
(ii)
make the information and documentation available to the Commissioner on request.
(f)
A carrier may not implement a producer commission schedule that varies the amount of a commission based on the size of a small employer group unless the variation:
(1)
is inversely related to the size of the small employer group;
(2)
applies to the cumulative premium paid over a specific period of time, is uniformly applied, and is inversely related to the cumulative premium paid during the period of time; or
(3)
is established by a contract between the carrier and each outside producer, and the carrier:
(i)
specifies in the contract the group size to which the variation applies;
(ii)
directs the outside producer to refer small employers of the specified size to an employee of the carrier who is a licensed producer or to a company affiliated with the carrier through common ownership within an insurance holding company; and
(iii)
pays a commission to the employee producer described in item (ii) of this item.
(g)
(1)
A licensed insurance producer, in connection with the sale, solicitation, or negotiation of a health benefit plan to a small employer, shall:
(i)
provide information to the small employer about wellness benefits; and
(ii)
advise the small employer to consult a tax advisor about the tax advantages of a payroll deduction plan under § 125 of the Internal Revenue Code.
(2)
The information shall be provided:
(i)
whenever the employer purchases or renews a health benefit plan; and
(ii)
on request.
(h)
(1)
In accordance with regulations adopted by the Commissioner, a licensed insurance producer may provide to a small employer information about the Maryland Medical Assistance Program and the Maryland Children’s Health Program for the small employer to distribute to its employees during the enrollment period.
(2)
The information provided under paragraph (1) of this subsection shall be restricted to general information about the Maryland Medical Assistance Program and the Maryland Children’s Health Program, including:
(i)
income eligibility thresholds; and
(ii)
application instructions.
Md. Code Ann., Ins. § 15-1207 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1207LinkCopy Citation
(a)
In accordance with Title 19, Subtitle 1 of the Health – General Article, the Commission shall adopt regulations that specify:
(1)
the Comprehensive Standard Health Benefit Plan to apply under this subtitle; and
(2)
the requirements for a wellness benefit offered by a carrier to apply under this subtitle.
(b)
(1)
Subject to paragraph (2) of this subsection, the Commission shall exclude or limit benefits or adjust cost–sharing arrangements in the Standard Plan if the average rate for the Standard Plan exceeds 10% of the average annual wage in the State.
(2)
The Commission annually shall determine the average rate for the Standard Plan by using the average rate submitted by each carrier that offers the Standard Plan.
(c)
In establishing benefits, the Commission shall judge preventive services, medical treatments, procedures, and related health services based on:
(1)
their effectiveness in improving the health status of individuals;
(2)
their impact on maintaining and improving health and on reducing the unnecessary consumption of health care services; and
(3)
their impact on the affordability of health care coverage.
(d)
The Commission may exclude:
(1)
a health care service, benefit, coverage, or reimbursement for covered health care services that is required under this article or the Health – General Article to be provided or offered in a health benefit plan that is issued or delivered in the State by a carrier; or
(2)
reimbursement required by statute, by a health benefit plan for a service when that service is performed by a health care provider who is licensed under the Health Occupations Article and whose scope of practice includes that service.
(e)
The Commission shall include mental health and substance abuse benefits required under § 15–802 of this title and § 19–703.1 of the Health – General Article for employers that meet the large employer definition under § 15–802 of this title and § 19–703.1 of the Health – General Article.
(f)
The Commission shall specify the deductibles and cost–sharing associated with the benefits in the Standard Plan.
(g)
In establishing cost–sharing as part of the Standard Plan, the Commission shall:
(1)
include cost–sharing and other incentives to help prevent consumers from seeking unnecessary services;
(2)
balance the effect of cost–sharing in reducing premiums and in affecting utilization of appropriate services; and
(3)
limit the total cost–sharing that may be incurred by an individual in a year.
(h)
Beginning January 1, 2014, this section applies only to grandfathered health plans as defined in § 1251 of the Affordable Care Act.
Md. Code Ann., Ins. § 15-1208 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1208LinkCopy Citation
The provisions of § 15–508 of this title apply to a policy or certificate issued to a small employer.
Md. Code Ann., Ins. § 15-1208.1 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1208.1LinkCopy Citation
(a)
A carrier shall provide the special enrollment periods described in this section in each small employer health benefit plan.
(b)
A carrier shall allow an eligible employee or dependent who is eligible, but not enrolled, for coverage under the terms of the employer’s health benefit plan to enroll for coverage under the terms of the plan if:
(1)
the eligible employee or dependent was covered under an employer–sponsored plan or group health benefit plan at the time coverage was previously offered to the employee or dependent;
(2)
the eligible employee states in writing, at the time coverage was previously offered, that coverage under an employer–sponsored plan or group health benefit plan was the reason for declining enrollment, but only if the plan sponsor or carrier requires the statement and provides the employee with notice of the requirement;
(3)
the eligible employee’s or dependent’s coverage described in item (1) of this subsection:
(i)
was under a COBRA continuation provision, and the coverage under that provision was exhausted; or
(ii)
was not under a COBRA continuation provision, and either the coverage was terminated as a result of loss of eligibility for the coverage, including loss of eligibility as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment, or employer contributions towards the coverage were terminated; and
(4)
under the terms of the plan, the eligible employee requests enrollment not later than 30 days after:
(i)
the date of exhaustion of coverage described in item (3)(i) of this subsection; or
(ii)
termination of coverage or termination of employer contributions described in item (3)(ii) of this subsection.
(c)
All small employer health benefit plans shall provide a special enrollment period during which the following individuals may be enrolled under the health benefit plan:
(1)
an individual who becomes a dependent of the eligible employee through marriage, birth, adoption, placement for adoption, or placement for foster care;
(2)
an eligible employee who acquires a new dependent through marriage, birth, adoption, placement for adoption, placement for foster care, or through a child support order or other court order;
(3)
the spouse of an eligible employee at the birth or adoption of a child, placement of a child for foster care, or through a child support order or other court order, provided the spouse is otherwise eligible for coverage;
(4)
at the option of the SHOP Exchange, an enrollee who is the eligible employee or the spouse of the eligible employee, if:
(i)
the enrollee loses a dependent or is no longer considered to be a dependent due to divorce or legal separation; or
(ii)
the employee or the employee’s dependent dies; and
(5)
(i)
an eligible employee who becomes pregnant, as confirmed by a health care practitioner; and
(ii)
an eligible employee’s spouse or dependent who becomes pregnant, as confirmed by a health care practitioner, provided the spouse or dependent is otherwise eligible for coverage.
(d)
An eligible employee may not enroll a dependent during a special enrollment period unless the eligible employee:
(1)
is enrolled under the health benefit plan; or
(2)
applies for coverage for the eligible employee during the same special enrollment period.
(e)
(1)
The special enrollment period under subsection (c)(1) through (4) of this section shall be a period of not less than 31 days and shall begin on the later of:
(i)
the date dependent coverage is made available; or
(ii)
the date of the marriage, birth, adoption, placement for adoption, placement for foster care, child support order or other court order, divorce, legal separation, or death, whichever is applicable.
(2)
The special enrollment period under subsection (c)(5) of this section shall:
(i)
be open for a period of 90 days; and
(ii)
begin on the date a health care practitioner confirms the pregnancy.
(f)
(1)
If an eligible employee enrolls any of the individuals described in subsection (c)(1) through (4) of this section during the first 31 days of the special enrollment period, the coverage shall become effective as follows:
(i)
in the case of marriage, not later than the first day of the first month beginning after the date the completed request for enrollment is received;
(ii)
in the case of a dependent’s birth, as of the date of the dependent’s birth;
(iii)
in the case of a dependent’s adoption or placement for adoption, the date of adoption or placement for adoption, whichever occurs first;
(iv)
in the case of a dependent’s placement for foster care, the date of placement; and
(v)
in the case of a dependent added due to a child support order or any other court order:
(1)
the date the child support order or other court order is effective; or
(2)
for SHOP Exchange plans, if allowed by the SHOP Exchange and selected by the eligible employee, the first day of the month following receipt of the plan selection.
(2)
If an eligible employee enrolls an individual described in subsection (c)(5) of this section in a health benefit plan, the coverage shall become effective on the first day of the month in which the individual receives confirmation of pregnancy.
(g)
If the SHOP Exchange allows the special enrollment periods described in subsection (c)(4) of this section, the coverage shall become effective as follows:
(1)
for special enrollment periods in the SHOP Exchange due to death of the employee or dependent, the first day of the month following plan selection; and
(2)
for special enrollment periods in the SHOP Exchange due to divorce or legal separation, the first day of the month following receipt of the plan selection.
Md. Code Ann., Ins. § 15-1208.2 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1208.2LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Dependent” means an individual who is or who may become eligible for coverage under the terms of a health benefit plan because of a relationship with an eligible employee.
(3)
“Qualifying coverage in an eligible employer–sponsored plan” has the meaning stated in 45 C.F.R. § 155.300.
(b)
(1)
A carrier shall establish a standardized annual open enrollment period of at least 30 days for each small employer.
(2)
The annual open enrollment period shall occur before the end of the small employer’s plan year.
(3)
During the annual open enrollment period, each eligible employee of the small employer shall be permitted to:
(i)
enroll in a health benefit plan offered by the small employer;
(ii)
discontinue enrollment in a health benefit plan offered by the small employer; or
(iii)
change enrollment from one health benefit plan offered by the small employer to a different health benefit plan offered by the small employer.
(c)
A carrier shall provide an open enrollment period of at least 30 days for each employee who becomes an eligible employee outside the initial or annual open enrollment period.
(d)
(1)
A carrier shall provide an open enrollment period for each individual who experiences a triggering event described in paragraph (4) of this subsection.
(2)
The open enrollment period shall be for at least 30 days, beginning on the date of the triggering event.
(3)
During the open enrollment period for an individual who experiences a triggering event, a carrier shall permit the individual to enroll in or change from one health benefit plan offered by the small employer to another health benefit plan offered by the small employer.
(4)
A triggering event occurs when:
(i)
subject to paragraph (5) of this subsection, an eligible employee or dependent loses minimum essential coverage;
(ii)
an eligible employee or a dependent loses:
(1)
pregnancy–related coverage described under § 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Social Security Act, which is considered to occur on the last day the eligible employee or dependent would have pregnancy–related coverage; or
(2)
access to health care services through a program providing prenatal care or services, which is considered to occur on the last day the eligible employee or dependent would have access to health care services;
(iii)
an eligible employee or a dependent loses medically needy coverage as described under § 1902(a)(10)(C) of the Social Security Act, which is considered to occur on the last day the eligible employee or dependent would have medically needy coverage;
(iv)
an eligible employee or a dependent who is enrolled in a qualified health plan in the SHOP Exchange adequately demonstrates to the SHOP Exchange that the qualified health plan in which the eligible employee or a dependent is enrolled substantially violated a material provision of the qualified health plan’s contract in relation to the eligible employee or a dependent;
(v)
an eligible employee or a dependent:
(1)
loses eligibility for coverage under a Medicaid plan under Title XIX of the Social Security Act or a state child health plan under Title XXI of the Social Security Act; or
(2)
becomes eligible for assistance, with respect to coverage under the SHOP Exchange, under a Medicaid plan or state child health plan, including any waiver or demonstration project conducted under or in relation to a Medicaid plan or a state child health plan;
(vi)
for SHOP Exchange health benefit plans:
(1)
an eligible employee’s or a dependent’s enrollment or nonenrollment in a qualified health plan is, as evaluated and determined by the Exchange:
(A)
unintentional, inadvertent, or erroneous; and
(B)
the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the Exchange or the federal Department of Health and Human Services, or its instrumentalities, or a non–Exchange entity providing enrollment assistance or conducting enrollment activities;
(2)
an eligible employee is an Indian as defined in § 4 of the federal Indian Health Care Improvement Act;
(3)
subject to paragraph (11) of this subsection, a material error related to plan benefits, service area, cost–sharing, or premium influenced the eligible employee’s or dependent’s decision to purchase a qualified health plan through the Exchange; or
(4)
an eligible employee or dependent demonstrates to the SHOP Exchange, in accordance with guidelines issued by the federal Department of Health and Human Services, that the eligible employee or a dependent meets other exceptional circumstances as the SHOP Exchange may provide;
(vii)
an eligible employee or dependent:
(1)
is a victim of domestic abuse or spousal abandonment, as defined by 26 C.F.R. § 1.36B–2T;
(2)
is enrolled in minimum essential coverage; and
(3)
seeks to enroll in coverage separate from the perpetrator of the abuse or abandonment;
(viii)
an eligible employee or dependent:
(1)
applies for coverage through the Individual Exchange during the annual open enrollment period or a special enrollment period;
(2)
is assessed by the Individual Exchange as potentially eligible for the Maryland Medical Assistance Program or the Maryland Children’s Health Program; and
(3)
is determined ineligible for the Maryland Medical Assistance Program or the Maryland Children’s Health Program by the Maryland Department of Health either:
(A)
after open enrollment has ended; or
(B)
more than 60 days after the qualifying event;
(ix)
an eligible employee or dependent:
(1)
applies for coverage through the Maryland Medical Assistance Program or the Maryland Children’s Health Program during the annual open enrollment period; and
(2)
is determined ineligible for the Maryland Medical Assistance Program or the Maryland Children’s Health Program after open enrollment has ended; or
(x)
an eligible employee or dependent gains access to new qualified health plans as a result of a permanent move and either:
(1)
had minimum essential coverage as described in 26 C.F.R. § 1.5000a–1(b) for 1 or more days during the 60 days before the date of the permanent move;
(2)
lived in a foreign country or in a United States territory for 1 or more days during the 60 days before the date of the permanent move;
(3)
lived in a service area where no qualified health plan was available through the Exchange:
(A)
for 1 or more days during the 60 days before the date of the permanent move; or
(B)
during the eligible employee’s or dependent’s most recent preceding open enrollment period or special enrollment period;
(4)
had coverage for prenatal care or services as described in 45 C.F.R. § 155.420(d)(1)(iii) for 1 or more days during the 60 days before the date of the permanent move; or
(5)
had medically needy coverage as described in 45 C.F.R. § 155.420(d)(1)(iv) for 1 or more days during the 60 days before the date of the permanent move.
(5)
Loss of minimum essential coverage under paragraph (4)(i) of this subsection does not include loss of coverage due to:
(i)
voluntary termination of coverage;
(ii)
failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; or
(iii)
a rescission authorized under 45 C.F.R. § 147.128.
(6)
The triggering event described in paragraph (4)(iii) of this subsection is permitted only once per year per individual.
(7)
If an eligible employee or a dependent meets the requirements for the triggering event described in paragraph (4)(vi)1 of this subsection, the Exchange may take any action necessary to correct or eliminate the effects of the error, misrepresentation, or inaction.
(8)
If an eligible employee meets the requirements for the triggering event described in paragraph (4)(vi)2 of this subsection, the eligible employee and a dependent may enroll in a qualified health plan or change from one qualified health plan to another one time per month.
(9)
An eligible employee or a dependent who meets the requirements for the triggering event described in paragraph (4)(v) of this subsection shall have 60 days from the triggering event to select a health benefit plan.
(10)
If a victim of domestic abuse or spousal abandonment meets the requirements for the triggering event described in paragraph (4)(vii) of this subsection, the victim’s dependents may enroll in a qualified health plan at the same time as the victim.
(11)
A material error under paragraph (4)(vi)3 of this subsection is an error that is likely to have influenced the enrollment of an eligible employee or the dependent of the eligible employee in a qualified health plan.
(e)
If an individual enrolls for coverage during one of the open enrollment periods described in this section, coverage shall be effective in accordance with the requirements in 45 C.F.R. § 155.420.
Md. Code Ann., Ins. § 15-1209 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1209LinkCopy Citation
(a)
This section does not apply to any insurance enumerated in § 15–1201(i)(3)(i) through (xiii) of this subtitle.
(b)
A carrier shall issue its health benefit plans to each small employer that meets the requirements of this section.
(c)
(1)
Nothing in this subsection requires a small employer to contribute to the premium payments for coverage of a dependent of an eligible employee.
(2)
To be covered under a health benefit plan offered by a carrier, a small employer shall:
(i)
elect to be covered;
(ii)
agree to pay the premiums;
(iii)
agree to offer coverage to any dependent of an eligible employee when coverage is sought by the eligible employee, in accordance with provisions governing late enrollees and any other provisions of this subtitle that apply to coverage;
(iv)
agree to collect payments for premiums through payroll deductions for coverage of eligible employees and dependents and transmit those payments to the carrier or the SHOP Exchange, as applicable; and
(v)
satisfy other reasonable provisions of the health benefit plan as approved by the Commissioner.
(d)
(1)
In determining whether a small employer satisfies the requirements of this section, a carrier shall apply its requirements uniformly among all small employers with the same number of eligible employees who apply for or receive coverage from the carrier, including a requirement that a minimum percentage of eligible employees of the small employer participate in the health benefit plan.
(2)
A carrier may vary application of minimum participation of eligible employees only by the size of the group of the small employer.
(e)
A carrier may not require a small employer to contribute to payment of premiums for a health benefit plan.
Md. Code Ann., Ins. § 15-1210 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1210LinkCopy Citation
(a)
A carrier that offers coverage to a small employer shall:
(1)
offer coverage to all of its eligible employees and all of their eligible dependents; and
(2)
at the election of the small employer, offer coverage to all of its part–time employees who have a normal workweek of at least 17 1/2 but less than 30 hours per week.
(b)
(1)
A health maintenance organization need not offer coverage:
(i)
to a small employer that is outside of the health maintenance organization’s approved service areas;
(ii)
to an eligible employee who resides outside of the health maintenance organization’s approved service areas; or
(iii)
within an area where the health maintenance organization reasonably anticipates, and demonstrates to the satisfaction of the Commissioner, that it will not have the capacity in its network of providers to deliver service adequately because of obligations to existing group contract holders and enrollees.
(2)
A health maintenance organization that does not offer coverage under paragraph (1)(iii) of this subsection may not offer coverage in the applicable area to any employer groups until the later of:
(i)
180 days after a refusal to do so; or
(ii)
the date on which the health maintenance organization notifies the Commissioner that it has regained capacity to deliver services to small employer groups in that area.
(c)
A carrier may not be required to offer coverage under §§ 15–1209 and 15–1213 of this subtitle for as long as the Commissioner finds that the coverage would place the carrier in a financially impaired condition.
Md. Code Ann., Ins. § 15-1211 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1211LinkCopy Citation
(a)
To sell health benefit plans to small employers in the State, a carrier shall file its proposed health benefit plans with the Commissioner on or before the date designated by the Commissioner.
(b)
Unless the Commissioner previously has disapproved a health benefit plan, it is deemed approved 60 days after filing with the Commissioner.
Md. Code Ann., Ins. § 15-1212 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1212LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Plan” means, with respect to a product, the pairing of the health benefits under the product with a particular cost–sharing structure, provider network, and service area.
(3)
(i)
“Product” means a discrete package of health benefits that are offered using a particular product network type within a geographic service area.
(ii)
“Product” comprises all plans offered within the product.
(4)
“Uniform modification of coverage” means a change to a small employer’s health benefit plan that meets the criteria stated in 45 C.F.R. § 147.106(e).
(b)
Changes in benefits made in accordance with federal or State requirements are not subject to the plus or minus 2 percentage points referenced in 45 C.F.R. § 147.106(e)(3)(v).
(c)
The combination of all plans offered with a product constitutes the total service area of the product.
(d)
(1)
With respect to a plan that has been modified at the time of coverage renewal consistent with this section, the plan shall be considered to be the same plan if:
(i)
(1)
the plan has the same cost–sharing structure as before the modification; or
(2)
any variation in cost sharing:
(A)
is solely related to changes in cost or utilization of medical care; or
(B)
is to maintain the same metal level described in § 1302(d) and (e) of the Affordable Care Act;
(ii)
the plan continues to cover a majority of the same service area; and
(iii)
the plan continues to cover a majority of the same provider network.
(2)
Notwithstanding paragraph (1) of this subsection, the plan shall be considered to be the same plan to the extent that the modifications are:
(i)
made uniformly and solely as a result of a federal or State requirement;
(ii)
made within a reasonable time period after the imposition or modification of the federal or State requirement; and
(iii)
directly related to the imposition or modification of the federal or State requirement.
(e)
(1)
Except as provided in subsections (f), (g), and (h) of this section, a carrier shall renew a health benefit plan at the option of the small employer.
(2)
On renewal, a carrier may not exclude eligible employees or dependents from a health benefit plan.
(3)
(i)
A carrier shall mail a notice of renewal to the small employer at least 60 days before the expiration of a health benefit plan.
(ii)
The notice of renewal shall include the dates of the renewal period, the health benefit plan rates, and the terms of coverage under the health benefit plan.
(4)
Policies or certificates for hospital or medical benefits issued through a professional employer organization, coemployer, or other organization under this subtitle may, with the consent of the carrier, have a common renewal date.
(f)
A carrier may cancel or refuse to renew a health benefit plan only:
(1)
for nonpayment of premiums;
(2)
for fraud or intentional misrepresentation of material fact by the small employer;
(3)
for noncompliance with a material plan provision relating to employer contributions or group participation rules;
(4)
when the carrier elects not to renew:
(i)
all of its health benefit plans that are issued to small employers in the State; or
(ii)
the particular product for all small employers in the State; or
(5)
in the case of a health maintenance organization, where there is no longer any enrollee who lives, resides, or works in the health maintenance organization’s approved service area, provided notice of the termination is provided to each small employer and to each employee covered under the health benefit plan at least 90 calendar days before the date coverage will be terminated.
(g)
When a carrier elects not to renew all health benefit plans in the State, the carrier:
(1)
shall give notice of its decision to the affected small employers and the insurance regulatory authority of each state in which an eligible employee or dependent resides at least 180 days before the effective date of nonrenewal;
(2)
shall give notice to the Commissioner at least 30 working days before giving the notice specified in item (1) of this subsection; and
(3)
may not write new business for small employers in the State for a period of 5 years beginning on the date of notice to the Commissioner.
(h)
When a carrier elects not to renew a particular product for all small employers in the State, the carrier shall:
(1)
provide notice of the nonrenewal at least 90 days before the date of the nonrenewal to:
(i)
each affected:
(1)
small employer; and
(2)
enrolled employee; and
(ii)
the Commissioner;
(2)
offer to each affected small employer the option to purchase all other health benefit plans currently offered by the carrier in the small group market; and
(3)
act uniformly without regard to the claims experience of any affected small employer, or any health status–related factor of any affected individual.
(i)
(1)
Within 7 days after cancellation or nonrenewal of a health benefit plan, the carrier shall send to each enrolled employee:
(i)
written notice of its action; and
(ii)
notice delivered by electronic means that complies with § 27–601.2 of this article.
(2)
The notice required under paragraph (1) of this subsection shall include information on additional health benefit coverage options, including continuation of coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA), if available, and plans available through the Maryland Health Benefit Exchange.
(j)
A carrier may make a uniform modification of coverage for a product only at the time of renewal of the health benefit plan.
(k)
A carrier will not be considered to have elected not to renew all health benefit plans that are issued to small employers in the State if the carrier complies with 45 C.F.R. § 147.106(d)(3).
Md. Code Ann., Ins. § 15-1213 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1213LinkCopy Citation
(a)
This section does not apply to any insurance enumerated in § 15–1201(i)(3)(i) through (xiii) of this subtitle.
(b)
Each benefit offered in addition to the Standard Plan that increases access to care choices or lowers the cost–sharing arrangement in the Standard Plan is subject to all of the provisions of this subtitle applicable to the Standard Plan, including:
(1)
guaranteed issuance;
(2)
guaranteed renewal; and
(3)
adjusted community rating.
(c)
(1)
Each benefit offered in addition to the Standard Plan that increases the type of services available or the frequency of services is not subject to guaranteed issuance but is subject to all other provisions of this subtitle applicable to the Standard Plan, including:
(i)
guaranteed renewal; and
(ii)
adjusted community rating.
(2)
For each additional benefit offered under this subsection, a carrier shall accept or reject the application of the entire group.
(3)
The Commissioner may prohibit a carrier from offering an additional benefit under this subsection if the Commissioner finds that the additional benefit will be sold in conjunction with the Standard Plan in a manner designed to promote risk selection or underwriting practices otherwise prohibited by this subtitle.
(d)
Beginning January 1, 2014, this section applies only to grandfathered health plans as defined in § 1251 of the Affordable Care Act.
Md. Code Ann., Ins. § 15-1214 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1214LinkCopy Citation
Notwithstanding any other provision of this subtitle, health benefit plans shall reimburse hospitals in accordance with rates approved by the State Health Services Cost Review Commission.
Md. Code Ann., Ins. § 15-1215 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1215LinkCopy Citation
(a)
(1)
Each carrier shall elect to become either a risk-assuming carrier or reinsuring carrier.
(2)
The notification of election to become a risk-assuming carrier shall include an appropriate opinion by an independent qualified actuary that the risk-assuming carrier is able to assume and manage the risk of enrolling groups under this subtitle without the protection of the Pool.
(b)
(1)
The initial election under this section is binding for 3 years.
(2)
After the initial 3 years, and every 5 years thereafter, each carrier shall again elect to be either a risk-assuming or reinsuring carrier.
(3)
Each subsequent election is binding for 5 years.
(4)
The Commissioner may allow a new carrier to make an election under conditions established by the Commissioner.
(c)
(1)
The Commissioner may allow a carrier to change its election at any time for good cause shown.
(2)
In determining whether to approve an application by a carrier to change its election, the Commissioner shall consider:
(i)
the applicant’s financial condition and the financial condition of any parent or guaranteeing corporation;
(ii)
the applicant’s history of assuming and managing risk;
(iii)
the applicant’s commitment to market fairly to all small employers in the State or in the applicant’s service area;
(iv)
the applicant’s ability to assume and manage the risk of enrolling groups under this subtitle without the protection of the Pool; and
(v)
the effect of approval of the application on the financial viability of the Pool.
(3)
While the Commissioner is considering an application under this subsection, the carrier may request a hearing as provided under Title 11, Subtitle 5 of this article.
Md. Code Ann., Ins. § 15-1216 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1216LinkCopy Citation
(a)
The Commissioner shall establish the Maryland Small Employer Health Reinsurance Pool.
(b)
The Pool shall be operational and may reinsure claims in accordance with this subtitle on or after July 1, 1994.
(c)
(1)
The reinsuring carriers shall elect a Board of Directors to be composed of seven members.
(2)
The Board shall include representation from carriers whose principal business in health insurance comprises small employers and, to the extent possible, at least one nonprofit health service plan, at least one commercial carrier, and at least one health maintenance organization.
(3)
A carrier, including its affiliates, may not be represented by more than one member on the Board.
(4)
The term of a member is 3 years except that the terms of initial members shall be staggered for periods of 1 to 3 years.
(5)
At the end of a term, a member continues to serve until a successor is elected.
(6)
Vacancies shall be filled by an election of the remaining Board members.
(7)
A member who is elected after a term has begun serves only for the rest of the term and until a successor is elected.
(8)
A member who serves two consecutive full 3–year terms may not be reelected for 3 years after the completion of those terms.
(d)
The Board shall choose a Chairman.
(e)
(1)
The Board shall appoint an Executive Director, who shall be the chief administrative officer of the Pool.
(2)
The Executive Director serves at the pleasure of the Board.
(3)
Under the direction of the Board, the Executive Director shall perform any duty or function that the Board requires.
(f)
The Pool may employ a staff in accordance with the budget of the Pool.
(g)
(1)
The Board shall submit to the Commissioner a plan of operation to ensure the fair, reasonable, and financially sound administration of the Pool.
(2)
The Commissioner may amend or rescind a plan of operation if the Commissioner finds that the Pool is not operating in a fair, reasonable, and financially sound manner.
Md. Code Ann., Ins. § 15-1217 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1217LinkCopy Citation
(a)
At a minimum, the plan of operation shall:
(1)
establish procedures for the handling and accounting of Pool assets and money and for an annual fiscal report to the Commissioner;
(2)
establish procedures for reinsuring claims submitted to the Pool in accordance with this subtitle;
(3)
establish procedures for collecting assessments from members to reinsure claims submitted to the Pool and to pay for administrative expenses incurred or estimated to be incurred during the period;
(4)
establish procedures for recouping any net losses to the Pool for the calendar year by assessing reinsuring carriers under § 15–1221 of this subtitle; and
(5)
provide for any additional matters at the discretion of the Board.
(b)
The Board has the general powers and authority granted under the laws of the State to health insurers and health maintenance organizations authorized to transact business, except for the power to issue health benefit plans directly to groups or individuals.
(c)
The Board may:
(1)
enter into contracts as necessary or proper to carry out this subtitle and, with approval of the Commissioner, enter into contracts with similar programs of other states for the joint performance of common functions or with persons or other organizations for the performance of administrative functions;
(2)
sue or be sued;
(3)
take any legal action necessary or proper to recover assessments and penalties for, on behalf of, or against the Pool or reinsuring carriers or necessary to avoid the payment of improper claims against the Board;
(4)
define the health benefit plans and medical conditions for which claims may be reinsured with the Pool in accordance with this subtitle;
(5)
establish rules, conditions, and procedures that relate to reinsurance of claims by the Pool;
(6)
establish actuarial functions as appropriate for the operation of the Pool;
(7)
assess reinsuring carriers in accordance with the provisions of § 15–1221 of this subtitle;
(8)
make advance interim assessments as may be reasonable and necessary for organizational and interim operating expenses, to be credited against any assessments due after the close of the fiscal year;
(9)
appoint appropriate committees as necessary to provide technical assistance in the operation of the Pool, policy and other contract design, and any other function within the authority of the Pool; and
(10)
borrow money to carry out the purposes of the Pool.
Md. Code Ann., Ins. § 15-1218 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1218LinkCopy Citation
(a)
A reinsuring carrier may reinsure with the Pool as provided in this section.
(b)
At a minimum, the Pool shall reinsure up to the level of coverage specified under the Standard Plan.
(c)
A reinsuring carrier may reinsure an entire employer group within 60 days after commencement of the group’s coverage under a health benefit plan.
(d)
(1)
A reinsuring carrier may reinsure an eligible employee or dependent within 60 days after commencement of coverage with the small employer.
(2)
A reinsuring carrier may reinsure a newly eligible employee or dependent within 60 days after commencement of coverage of the eligible employee or dependent.
(e)
(1)
The Pool may not reimburse a reinsuring carrier with respect to the claims of an individual until the reinsuring carrier has incurred claims for the individual of $5,000 in a calendar year for benefits covered by the Pool.
(2)
After the initial $5,000 of incurred claims, the reinsuring carrier is responsible for 10% of the next $50,000 of incurred claims during the calendar year, and the Pool shall reinsure the remainder.
(3)
The liability of a reinsuring carrier under this subsection may not exceed $10,000 in any 1 calendar year with respect to any individual.
(f)
(1)
The Board annually shall adjust the initial level of claims and the maximum limit to be retained by the reinsuring carrier to reflect increases in costs and utilization within the standard market for health benefit plans in the State.
(2)
Unless the Board proposes and the Commissioner approves a lower adjustment factor, the adjustment in paragraph (1) of this subsection may not be less than the annual change in the medical component of the “Consumer Price Index for all Urban Consumers” of the Department of Labor, Bureau of Labor Statistics.
(g)
A reinsuring carrier may terminate reinsurance on a plan anniversary for one or more of the individuals in a small employer group.
Md. Code Ann., Ins. § 15-1219 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1219LinkCopy Citation
(a)
(1)
(i)
As part of the plan of operation, the Board shall establish a methodology to determine premium rates to be charged by the Pool to reinsure small employers and individuals under this section and § 15-1218 of this subtitle.
(ii)
The methodology shall provide for the development of base reinsurance premium rates that shall be multiplied by the factors set forth in paragraph (2) of this subsection to determine the premium rates for the Pool.
(iii)
The Board shall establish the base reinsurance premium rates at levels that reasonably approximate gross premiums charged to small employers by carriers for health benefit plans up to the level of coverage that the Board determines.
(2)
Premiums for the Pool shall be as follows:
(i)
an entire group may be reinsured for a rate that is 1.5 times the base reinsurance premium rate for the group established under this subsection; and
(ii)
an individual may be reinsured for a rate that is 5 times the base reinsurance premium rate for the individual established under this subsection.
(3)
(i)
The Board periodically shall review the methodology established under paragraph (1) of this subsection, including the system of classification and any rating factors, to ensure that it reasonably reflects the claims experience of the Pool.
(ii)
The Board may propose changes to the methodology, subject to the approval of the Commissioner.
(b)
If a health benefit plan for a small employer is entirely or partially reinsured with the Pool, the premium charged to the small employer for any rating period for the coverage issued shall meet the requirements that relate to premium rates set forth in § 15-1205 of this subtitle.
Md. Code Ann., Ins. § 15-1220 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1220LinkCopy Citation
(a)
The Pool shall manage and invest all money collected by or on behalf of the Pool through premium charges, assessments, earnings from investments, or otherwise, through a financial management committee composed of the Executive Director and two members of the Board.
(b)
All operating expenses of the Pool shall be paid from funds collected by or on behalf of the Pool.
(c)
The account of the Pool is a special fund account and the money in the account is not part of the General Fund of the State.
(d)
The State may not provide General Fund appropriations to the Pool and the obligations of the Pool are not a debt of the State or a pledge of the credit of the State.
(e)
All debts, claims, obligations, and liabilities of the Pool, whenever incurred, shall be the debts, claims, obligations, and liabilities of the Pool only and not of the State or the State’s agencies, instrumentalities, officers, or employees.
(f)
The Pool is exempt from:
(1)
taxation by the State and local government;
(2)
the general procurement law provisions of Division II of the State Finance and Procurement Article; and
(3)
Division I of the State Personnel and Pensions Article.
Md. Code Ann., Ins. § 15-1221 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1221LinkCopy Citation
(a)
On or before the last day of February of each year, the Board shall determine and report to the Commissioner the net loss of the Pool for the previous calendar year, including administrative expenses and incurred losses for the year, taking into account investment income and other appropriate gains and losses.
(b)
Any net loss for the year shall be recouped by assessments imposed on reinsuring carriers.
(c)
(1)
As part of the plan of operation, the Board shall establish a formula to make assessments against reinsuring carriers.
(2)
The assessment formula shall be based on:
(i)
each reinsuring carrier’s share of the total premiums earned in the preceding calendar year from health benefit plans that are delivered or issued for delivery to small employers in the State by reinsuring carriers; and
(ii)
each reinsuring carrier’s share of the premiums earned in the preceding calendar year from newly issued health benefit plans that are delivered or issued for delivery during that calendar year to small employers in the State by reinsuring carriers.
(3)
The assessment formula may not result in an assessment share for a reinsuring carrier that is less than 50% nor more than 150% of an amount that is based on the proportion of the reinsuring carrier’s total premiums earned in the preceding calendar year from health benefit plans that are delivered or issued for delivery to small employers in the State to total premiums earned by all reinsuring carriers in the preceding calendar year from health benefit plans that are delivered or issued for delivery to small employers in the State.
(4)
As appropriate and with the approval of the Commissioner, the Board may change the assessment formula established in accordance with this subsection.
(5)
The Board may provide for assessment shares attributable to premiums from all health benefit plans and to premiums from newly issued health benefit plans to vary during a transition period.
(6)
Subject to approval by the Commissioner, the Board shall make an adjustment to the assessment formula for reinsuring carriers that are approved health maintenance organizations and that are federally qualified under the Health Maintenance Organization Act of 1973 to the extent that restrictions are imposed on the health maintenance organizations that are not imposed on other carriers.
(7)
Premiums and benefits paid by a reinsuring carrier that are less than an amount determined by the Board to justify the cost of collection may not be considered in determining assessments.
(d)
(1)
On or before the last day of February of each year, the Board shall determine and file with the Commissioner an estimate of the assessments needed to fund the losses incurred by the Pool in the previous calendar year.
(2)
If the Board determines that the assessments needed to fund the losses incurred by the Pool in the previous calendar year will exceed 5% of the total premiums earned that year from health benefit plans that are delivered or issued for delivery in the State, the Board shall evaluate the operation of the Pool and report its findings to the Commissioner within 90 days after the end of the calendar year in which the losses were incurred.
(3)
The evaluation required under paragraph (2) of this subsection shall include:
(i)
any recommendations for changes to the plan of operation;
(ii)
an estimate of future assessments;
(iii)
the administrative costs of the Pool;
(iv)
the appropriateness of the premiums charged;
(v)
the level of insurer retention under the Pool; and
(vi)
the costs of coverage for small employers.
(4)
If the Board fails to file the report with the Commissioner within 90 days after the end of the applicable calendar year, the Commissioner may evaluate the operations of the Pool and implement amendments to the plan of operation that the Commissioner considers necessary to reduce future losses and assessments.
(e)
If assessments exceed net losses of the Pool, the excess shall be held in an interest-bearing account and used by the Board to offset future losses, including reserves for incurred but not reported claims, or to reduce Pool premiums.
(f)
The Board annually shall determine the assessment share of each reinsuring carrier based on annual statements and other reports that the Board considers necessary and that reinsuring carriers file with the Board.
(g)
The plan of operation shall provide for imposition of an interest penalty for late payment of assessments.
(h)
(1)
(i)
A reinsuring carrier may seek from the Commissioner a deferment from all or part of an assessment imposed by the Board.
(ii)
The request for deferment shall be made in writing to the Commissioner within 15 days after receipt of the assessment notice.
(2)
The Commissioner may defer all or part of the assessment of a reinsuring carrier if the Commissioner determines that payment of the assessment would place the reinsuring carrier in a financially impaired condition.
(3)
(i)
Any amount deferred shall be assessed against the other reinsuring carriers in a manner consistent with the basis for assessment set forth in this section.
(ii)
The reinsuring carrier receiving the deferment remains liable to the Pool for the amount deferred and may not reinsure any individuals or groups in the Pool until it pays that amount.
Md. Code Ann., Ins. § 15-1222 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1222LinkCopy Citation
(a)
(1)
The Board shall report to the Commissioner on or before June 1 of each year.
(2)
At a minimum, the report shall include:
(i)
a description of the operations of the Pool for the preceding calendar year;
(ii)
an audited statement of the financial condition of the Pool as of the preceding December 31; and
(iii)
an audited detailed statement of the revenues received and expenditures of the Pool made during the preceding calendar year.
(b)
The operations of the Board are subject to an annual audit by an independent auditor, and the audit report and working papers are subject to review by the Legislative Auditor.
Md. Code Ann., Ins. § 15-1223 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1223LinkCopy Citation
Participation in the Pool as reinsuring carriers, establishment of rates, forms, or procedures, or any other joint or collective action required by §§ 15-1218, 15-1219, and 15-1221 of this subtitle may not be the basis of any legal action, criminal or civil liability, or penalty against the Pool or any of its reinsuring carriers either jointly or separately.
Md. Code Ann., Ins. § 15-1224 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1224LinkCopy Citation
The Commissioner may order the dissolution of the Pool if the Commissioner determines that the Pool is not financially viable, and provision is made to ensure the protection of those insured by the members of the Pool.
Md. Code Ann., Ins. § 15-1225 (2026)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act
§ 15–1225LinkCopy Citation
This subtitle is the Maryland Health Insurance Reform Act.
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
Md. Code Ann., Ins. § 15-1301 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1301LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Affiliation period” means a period of time beginning on the date of enrollment and not to exceed 2 months, or 3 months in the case of a late enrollee, during which a health maintenance organization does not collect premium, and coverage issued does not become effective.
(c)
“Association” or “bona fide association” means an association that:
(1)
has been actively in existence for at least 5 years;
(2)
has been formed and maintained in good faith for purposes other than obtaining insurance and does not condition membership on the purchase of association–sponsored insurance;
(3)
does not condition membership in the association on any health status–related factor relating to an individual, and states so clearly in all membership and application materials;
(4)
makes health insurance coverage offered through the association available to all members regardless of any health status–related factor relating to the members or individuals eligible for coverage and states so clearly in all membership and application materials;
(5)
does not make health insurance coverage offered through the association available other than in connection with membership in the association, and states so clearly in all marketing and application materials; and
(6)
provides and annually updates information necessary for the Commissioner to determine whether or not the association meets the definition of bona fide association before qualifying as an association under this subtitle.
(d)
“Benefit year” means a calendar year in which a health benefit plan provides coverage for health benefits.
(e)
“Carrier” means a person that is:
(1)
an insurer that holds a certificate of authority in the State and provides health insurance in the State;
(2)
a health maintenance organization that is licensed to operate in the State;
(3)
a nonprofit health service plan that is licensed to operate in the State; or
(4)
any other person or organization that provides health benefit plans subject to State insurance regulation.
(f)
“Church plan” means a plan as defined under § 3(33) of the Employee Retirement Income Security Act of 1974.
(g)
“Eligible individual” means an individual who applies for or is covered under an individual health benefit plan.
(h)
“Employer sponsored plan” means an employee welfare benefit plan that provides medical care to employees or their dependents, and is not subject to State regulation in accordance with the federal Employee Retirement Income Security Act of 1974.
(i)
“Enrollment date” means the date on which:
(1)
an individual enrolls in a health benefit plan; or
(2)
the first day of the waiting period before which the individual may enroll.
(j)
“Governmental plan” means a plan as defined in § 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan.
(k)
“Grandfathered health plan coverage” has the meaning stated in 45 C.F.R. § 147.140.
(l)
(1)
“Health benefit plan” means a:
(i)
hospital or medical policy or certificate, including those issued under multiple employer trusts or associations located in Maryland or any other state covering Maryland residents;
(ii)
policy, contract, or certificate issued by a nonprofit health service plan that covers Maryland residents; or
(iii)
health maintenance organization subscriber or group master contract.
(2)
“Health benefit plan” does not include:
(i)
one or more, or any combination of the following:
(1)
coverage only for accident or disability income insurance;
(2)
coverage issued as a supplement to liability insurance;
(3)
liability insurance, including general liability insurance and automobile liability insurance;
(4)
workers’ compensation or similar insurance;
(5)
automobile medical payment insurance;
(6)
credit–only insurance; and
(7)
coverage for on–site medical clinics;
(ii)
the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of a plan:
(1)
limited scope dental or vision benefits; and
(2)
benefits for long–term care, nursing home care, home health care, community–based care, or any combination of these benefits;
(iii)
coverage only for a specified disease or illness if offered as independent, noncoordinated benefits;
(iv)
hospital indemnity or other fixed indemnity insurance if:
(1)
offered as independent, noncoordinated benefits;
(2)
the benefits are paid in a fixed dollar amount per period of hospitalization, illness, or service, regardless of the amount of expenses incurred and of the amount of benefits provided with respect to the event or service under any other health coverage; and
(3)
a notice is displayed prominently in the application materials, in at least 14 point type, that has the following language in capital letters: “This is a supplement to health insurance and is not a substitute for major medical coverage. Lack of major medical coverage (or other minimum essential coverage) may result in an additional payment with your taxes.”; or
(v)
the following benefits if offered as a separate insurance policy:
(1)
Medicare supplemental health insurance (as defined under § 1882(g)(1) of the Social Security Act);
(2)
coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and
(3)
similar supplemental coverage provided to coverage under a group health plan if the coverage qualifies for the exception described in 45 C.F.R. § 146.145(b)(5)(i)(C).
(m)
“Health status–related factor” means a factor related to:
(1)
health status;
(2)
medical condition;
(3)
claims experience;
(4)
receipt of health care;
(5)
medical history;
(6)
genetic information;
(7)
evidence of insurability including conditions arising out of acts of domestic violence; or
(8)
disability.
(n)
“Individual Exchange” has the meaning stated in § 31–101 of this article.
(o)
(1)
“Individual health benefit plan” means:
(i)
a health benefit plan other than a converted policy or a professional association plan for eligible individuals and their dependents; or
(ii)
a certificate issued to an eligible individual that evidences coverage under a policy or contract issued to a trust or association or other similar group of individuals, regardless of the situs of delivery of the policy or contract, if the eligible individual pays the premium and is not being covered under the policy or contract under either federal or State continuation of benefits provisions.
(2)
“Individual health benefit plan” does not include short–term limited duration insurance.
(p)
“Minimum essential coverage” has the meaning stated in 45 C.F.R. § 155.20.
(q)
“Preexisting condition” means a condition that was present before the date of enrollment for coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.
(r)
“Qualified health plan” has the meaning stated in § 31–101 of this article.
(s)
“Short–term limited duration insurance” means health insurance coverage provided under a policy or contract with a carrier and that:
(1)
has a policy term that is less than 3 months after the original effective date of the policy or contract;
(2)
may not be extended or renewed;
(3)
applies the same underwriting standards to all applicants regardless of whether they have previously been covered by short–term limited duration insurance; and
(4)
contains the notice required by federal law prominently displayed in the contract and in any application materials provided in connection with enrollment.
(t)
“Waiting period” means the period of time that must pass before an individual is eligible to be covered for benefits under the terms of a group health benefit plan.
Md. Code Ann., Ins. § 15-1302 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1302LinkCopy Citation
(a)
This subtitle applies to all carriers that offer health benefit plans to individuals in the State.
(b)
This subtitle does not apply to a carrier that offers only conversion policies as required by law.
(c)
This subtitle does not apply to a carrier that offers health insurance coverage only in connection with group health plans.
Md. Code Ann., Ins. § 15-1303 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1303LinkCopy Citation
(a)
In addition to any other requirements under this article, a carrier that offers individual health benefit plans in the State shall:
(1)
have demonstrated the capacity to administer the individual health benefit plans, including adequate numbers and types of administrative staff;
(2)
have a satisfactory grievance procedure and ability to respond to calls, questions, and complaints from enrollees or insureds; and
(3)
design policies to help ensure that enrollees or insureds have adequate access to providers of health care.
(b)
(1)
Except as provided in this subsection and § 31–110(f) of this article, a carrier may not offer individual health benefit plans in the State unless the carrier also offers qualified health plans, as defined in § 31–101 of this article, in the Individual Exchange of the Maryland Health Benefit Exchange in compliance with the requirements of Title 31 of this article.
(2)
A carrier is exempt from the requirement in paragraph (1) of this subsection if:
(i)
(1)
the reported total aggregate annual earned premium from all individual health benefit plans in the State for the carrier and any other carriers in the same insurance holding company system, as defined in § 7–101 of this article, is less than $10,000,000; or
(2)
the only individual health benefit plans that the carrier offers in the State are student health plans as defined in 45 C.F.R. § 147.145;
(ii)
the Commissioner determines that the carrier complies with the procedures established under paragraph (3) of this subsection; and
(iii)
when the carrier ceases to meet the requirements for the exemption, the carrier provides to the Commissioner immediate notice and its plan for complying with the requirement in paragraph (1) of this subsection.
(3)
The Commissioner shall establish procedures for a carrier to submit evidence each year that the carrier meets the requirements necessary to qualify for an exemption under paragraph (2) of this subsection.
(4)
Notwithstanding the exemption provided in paragraph (2) of this subsection, any carrier that offers a catastrophic plan, as defined by the Affordable Care Act, in the State also must offer at least one catastrophic plan in the Maryland Health Benefit Exchange.
(5)
Notwithstanding the exemption provided in paragraph (2) of this subsection, the Commissioner, in consultation with the Maryland Health Benefit Exchange:
(i)
may assess the impact of the exemption provided in paragraph (2) of this subsection and, based on that assessment, alter the limit on the amount of annual premiums that may not be exceeded to qualify for the exemption; and
(ii)
shall make any change in the exemption requirement by regulation.
Md. Code Ann., Ins. § 15-1307 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1307LinkCopy Citation
(a)
The actuarial value of benefits provided under individual health insurance coverage shall be calculated based on a standardized population and a set of standardized utilization and cost factors.
(b)
A carrier shall submit any information the Commissioner may require to support and justify the carrier’s calculations of actuarial values.
Md. Code Ann., Ins. § 15-1308 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1308LinkCopy Citation
(a)
In this section, “affiliate” means a person that directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with another person.
(b)
A carrier may elect not to renew all individual health benefit plans in the State.
(c)
When a carrier elects not to renew all individual health benefit plans in the State, the carrier:
(1)
shall give notice of its decision to the affected individuals at least 180 days before the effective date of nonrenewal;
(2)
at least 30 working days before that notice, shall give notice to the Commissioner;
(3)
if the carrier has an affiliate in the individual market, shall give notice to each affected individual at least 180 days before the effective date of nonrenewal of the individual’s option to purchase all other individual health benefit plans currently offered by the affiliate of the carrier; and
(4)
may not write new business for individuals in the State for a 5-year period beginning on the date of notice to the Commissioner.
(d)
A carrier that offers an individual health benefit plan shall offer an individual health benefit plan to an individual who is nonrenewed by an affiliate of the carrier under subsection (c) of this section on a guarantee issue basis, if the individual applies for coverage no later than 63 days after the effective date of nonrenewal.
(e)
A carrier that issues coverage under subsection (d) of this section may not rate the coverage on a substandard basis unless the individual was rated on a substandard basis under the prior coverage provided to the individual by the affiliate of the carrier.
(f)
(1)
Subject to paragraph (2) of this subsection, a carrier that issues coverage under subsection (d) of this section shall waive the waiting period for coverage of a preexisting condition to the extent that the individual has satisfied a waiting period under the individual’s prior contract or policy.
(2)
The carrier that issues coverage under subsection (d) of this section may require the individual to satisfy the remaining part of the waiting period if any part of the waiting period under the individual’s prior contract or policy has not been satisfied, unless the coverage issued under subsection (d) of this section has a shorter waiting period.
(g)
A health maintenance organization need not offer coverage to an individual who does not live, reside, or work within the health maintenance organization’s approved service areas.
(h)
A carrier will not be considered to have elected not to renew all individual health benefit plans in the State if the carrier complies with 45 C.F.R. § 147.106(d)(3).
Md. Code Ann., Ins. § 15-1309 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1309LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Plan” means, with respect to a product, the pairing of the health benefits under the product with a particular cost–sharing structure, provider network, and service area.
(3)
(i)
“Product” means a discrete package of health benefits that are offered using a particular product network type within a geographic service area.
(ii)
“Product” comprises all plans offered within the product.
(4)
“Uniform modification of coverage” means a change to a health benefit plan that meets the criteria stated in 45 C.F.R. § 147.106(e).
(b)
Changes in benefits made to comply with federal or State requirements are not subject to the plus or minus 2 percentage points referenced in 45 C.F.R. § 147.106(e)(3)(v).
(c)
The combination of all plans offered with a product constitutes the total service area of the product.
(d)
(1)
With respect to a plan that has been modified at the time of coverage renewal consistent with this section, the plan shall be considered to be the same plan if:
(i)
(1)
the plan has the same cost–sharing structure as before the modification; or
(2)
any variation in cost sharing:
(A)
is solely related to changes in cost or utilization of medical care; or
(B)
is to maintain the same metal level described in § 1302(d) and (e) of the Affordable Care Act;
(ii)
the plan continues to cover a majority of the same service area; and
(iii)
the plan continues to cover a majority of the same provider network.
(2)
Notwithstanding paragraph (1) of this subsection, the plan shall be considered to be the same plan to the extent that the modifications are:
(i)
made uniformly and solely as a result of a federal or State requirement;
(ii)
made within a reasonable time period after the imposition or modification of the federal or State requirement; and
(iii)
directly related to the imposition or modification of the federal or State requirement.
(e)
Except as provided in subsection (f) of this section, a carrier shall renew an individual health benefit plan at the option of the eligible individual.
(f)
A carrier may not cancel or refuse to renew an individual health benefit plan except:
(1)
for nonpayment of the required premiums;
(2)
where the individual has performed an act or practice that constitutes fraud;
(3)
where the individual has made an intentional misrepresentation of material fact under the terms of the coverage;
(4)
where the carrier elects not to renew all of its individual health benefit plans in the State in accordance with this article;
(5)
where the individual no longer resides, lives, or works in the service area, provided that:
(i)
the coverage is terminated under this provision uniformly without regard to any health status–related factor of covered individuals; and
(ii)
notice of the termination is provided to the individual at least 90 calendar days before the date coverage will be terminated; or
(6)
for individual health benefit plans that are not grandfathered health plans, as defined in 45 C.F.R. § 147.140, where a carrier discontinues offering a particular product in the individual market, if the carrier:
(i)
at least 90 days before discontinuation of the product, provides notice of the discontinuation to each individual provided coverage under the product;
(ii)
offers each individual provided coverage under the product the option to purchase any other individual health benefit plan coverage offered by the carrier for individuals in the State; and
(iii)
acts uniformly without regard to any health status–related factor of enrolled individuals or individuals who may become eligible for the coverage.
(g)
A carrier may make a uniform modification of coverage for a product only at the time of renewal of the health benefit plan.
(h)
A carrier shall provide notice of renewal or uniform modification of coverage for:
(1)
grandfathered health plan coverage, at least 60 days before the date the coverage will be renewed; and
(2)
a health benefit plan that is not grandfathered health plan coverage, before the date of the first day of the next annual open enrollment period, in a form and manner specified by the Secretary of Health and Human Services.
(i)
A carrier may not cancel or refuse to renew an individual health benefit plan because an eligible individual is entitled to or enrolled in Medicare if the eligible individual is renewing coverage under the same policy or contract of insurance.
Md. Code Ann., Ins. § 15-1313 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1313LinkCopy Citation
The Administration shall provide on its Web site and in printed form on request a list of carriers, including contact information for each carrier, that offer individual health benefit plans in the State.
Md. Code Ann., Ins. § 15-1314 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1314LinkCopy Citation
(a)
Except as provided in subsection (c) of this section, a carrier may not increase an individual’s premium on an individual health benefit plan more frequently than once every 12 months.
(b)
An increase in an individual’s premium described in subsection (a) of this section includes an increase due to the individual moving into a higher age band.
(c)
A carrier may increase an individual’s premium on an individual health benefit plan more frequently than once every 12 months if the premium increase is due solely to the enrollment of a new family member to the individual health benefit plan of the individual.
Md. Code Ann., Ins. § 15-1315 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1315LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Individual Exchange” has the meaning stated in § 31–101 of this article.
(3)
“Qualified health plan” has the meaning stated in § 31–101 of this article.
(4)
“Qualified individual” has the meaning stated in § 31–101 of this article.
(b)
This section applies to a qualified health plan that is issued on or after January 1, 2014, by a carrier through the Individual Exchange.
(c)
A qualified health plan subject to this section shall include a grace period provision applicable to a qualified individual who:
(1)
is receiving advance payments of federal premium tax credits; and
(2)
fails to pay premiums timely.
(d)
The grace period provision shall:
(1)
provide a grace period of 3 consecutive months after the initial premium payment to begin coverage has been paid;
(2)
apply to qualified health plans renewed in accordance with § 15–1309 of this subtitle without the qualified individual having to pay the first month’s premium following renewal; and
(3)
be in addition to any other grace period provision required by any other applicable State law.
(e)
During the grace period, a carrier that issues a qualified health plan subject to this section:
(1)
shall pay all appropriate claims for services rendered to the qualified individual during the first month of the grace period;
(2)
may pend claims for services rendered to the qualified individual in the second and third months of the grace period;
(3)
shall notify the federal Department of Health and Human Services that the qualified individual is in the grace period; and
(4)
shall notify providers of the possibility that claims may be denied when a qualified individual is in the second and third months of the grace period.
Md. Code Ann., Ins. § 15-1316 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1316LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Dependent” means an individual who is or who may become eligible for coverage under the terms of a health benefit plan because of a relationship with another individual.
(3)
“Health care practitioner” has the meaning stated in § 1–301 of the Health Occupations Article.
(4)
“Provider” means a health care practitioner or a health care facility that participates on a health benefit plan’s provider panel.
(5)
“Qualifying coverage in an eligible employer–sponsored plan” has the meaning stated in 45 C.F.R. § 155.300.
(b)
(1)
Beginning November 15, 2014, unless an alternative date is adopted by the federal Department of Health and Human Services, a carrier that sells health benefit plans to individuals in the State shall establish an annual open enrollment period.
(2)
The annual open enrollment period for 2014 shall begin on November 15, 2014, and extend through January 15, 2015, unless alternative dates are adopted by the federal Department of Health and Human Services.
(3)
The annual open enrollment period for years beginning on and after January 1, 2015, shall be:
(i)
the dates adopted by the federal Department of Health and Human Services; or
(ii)
if authorized by the federal Department of Health and Human Services, the dates adopted by the Exchange.
(4)
During the annual open enrollment period, an individual shall be permitted to:
(i)
enroll in a health benefit plan offered by the carrier;
(ii)
discontinue enrollment in a health benefit plan offered by the carrier; or
(iii)
change enrollment in a health benefit plan offered by the carrier to a different health benefit plan offered by the carrier.
(5)
If an individual enrolls in a health benefit plan offered by the carrier during the annual open enrollment period for 2014, the effective date of coverage shall be:
(i)
January 1, 2015, if the application is received by the carrier on or before December 15, 2014, unless an alternative date is adopted by the federal Department of Health and Human Services;
(ii)
February 1, 2015, if the application is received by the carrier from December 16, 2014, through January 15, 2015, unless an alternative date is adopted by the federal Department of Health and Human Services; and
(iii)
March 1, 2015, if the application is received by the carrier from January 16, 2015, through February 15, 2015, unless an alternative date is adopted by the federal Department of Health and Human Services.
(6)
If an individual enrolls in a health benefit plan offered by the carrier during the annual open enrollment period for years beginning on and after January 1, 2015, the effective date of coverage shall be:
(i)
the date adopted by the federal Department of Health and Human Services; or
(ii)
if authorized by the federal Department of Health and Human Services, the date adopted by the Exchange.
(c)
A carrier participating in the Individual Exchange shall provide:
(1)
the special enrollment periods specified in 45 C.F.R. § 155.420 for individuals who purchase coverage through the Individual Exchange;
(2)
a special enrollment period for an individual who purchases coverage through the Individual Exchange if the individual or a dependent of the individual becomes pregnant, as confirmed by a health care practitioner; and
(3)
a special enrollment period for an individual who purchases coverage through the Individual Exchange if the individual or a dependent of the individual is:
(i)
a patient being treated on a regular basis by or at a provider; and
(ii)
enrolled in a health benefit plan in which the provider treating the individual or dependent is terminated from the health benefit plan’s provider panel.
(d)
A carrier shall provide:
(1)
the special enrollment periods specified in 45 C.F.R. § 147.104(b)(2) for individuals who purchase coverage outside the Individual Exchange;
(2)
a special enrollment period for an individual who purchases coverage outside the Individual Exchange if the individual or a dependent of the individual becomes pregnant, as confirmed by a health care practitioner; and
(3)
a special enrollment period for an individual who purchases coverage outside the Individual Exchange if the individual or a dependent of the individual is:
(i)
a patient being treated on a regular basis by or at a provider; and
(ii)
enrolled in a health benefit plan in which the provider treating the individual or dependent is terminated from the health benefit plan’s provider panel.
(e)
(1)
A special enrollment period described in subsection (c)(2) or (d)(2) of this section shall:
(i)
be open for a period of 90 days; and
(ii)
begin on the date the health care practitioner confirms the pregnancy.
(2)
A special enrollment period described in subsection (c)(3) or (d)(3) of this section shall:
(i)
be open for a period of 90 days; and
(ii)
begin on:
(1)
the date of termination of the provider from the health benefit plan’s provider panel; or
(2)
if the consumer did not receive notice of the termination before the termination date, the date of the notice of termination.
(f)
(1)
If an individual enrolls for coverage during one of the open enrollment periods described in subsection (b) of this section or during one of the special open enrollment periods described in subsections (c)(1) and (d)(1) of this section, coverage shall be effective in accordance with the requirements in 45 C.F.R. § 155.420.
(2)
If an individual enrolls for coverage or enrolls a dependent for coverage during a special enrollment period described in subsection (c)(2) or (d)(2) of this section, the coverage shall become effective on the first day of the month in which the individual receives confirmation of pregnancy.
(3)
If an individual enrolls for coverage or enrolls a dependent for coverage during a special enrollment period described in subsection (c)(3) or (d)(3) of this section, the individual shall select if coverage shall become effective:
(i)
on the first day of the month following the date the health benefit plan was selected; or
(ii)
on the first day of the month in which the termination of the provider on the health benefit plan’s provider panel became effective.
(g)
(1)
A health maintenance organization may:
(i)
limit the individuals who may apply for coverage to those who live or reside in the health maintenance organization’s service area; and
(ii)
deny coverage to individuals if the health maintenance organization has demonstrated to the Commissioner that:
(1)
it will not have the capacity to deliver services adequately to any additional individuals because of its obligations to existing enrollees; and
(2)
it is applying the provisions of this paragraph uniformly to all individuals without regard to the claims experience of those individuals and their dependents or any health status–related factor relating to the individuals and their dependents.
(2)
A health maintenance organization that denies coverage to an individual in accordance with paragraph (1) of this subsection may not offer coverage in the individual market within the service area to any individual for a period of 180 days after the date the coverage is denied.
(3)
Paragraph (2) of this subsection does not:
(i)
limit the health maintenance organization’s ability to renew coverage already in force; or
(ii)
relieve the health maintenance organization of the responsibility to renew coverage already in force.
(h)
(1)
A carrier may deny a health benefit plan to an individual if the carrier has demonstrated to the Commissioner that:
(i)
it does not have the financial reserves necessary to offer additional coverage; and
(ii)
it is applying the provisions of this paragraph uniformly to all individuals in the individual market in the State without regard to the claims experience of those individuals and their dependents or any health status–related factor relating to the individuals and their dependents.
(2)
A carrier that denies a health benefit plan to an individual in the State under paragraph (1) of this subsection may not offer coverage in the individual market before the later of:
(i)
the 181st day after the date the carrier denies coverage; and
(ii)
the date the carrier demonstrates to the Commissioner that the carrier has sufficient financial reserves to underwrite additional coverage.
(3)
Paragraph (2) of this subsection does not:
(i)
limit the carrier’s ability to renew coverage already in force; or
(ii)
relieve the carrier of the responsibility to renew coverage already in force.
(4)
Health benefit plans offered after the time period described in paragraph (2) of this subsection are subject to the requirements of this section.
Md. Code Ann., Ins. § 15-1317 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1317LinkCopy Citation
(a)
A carrier that sells health benefit plans to individuals in the State shall establish an initial open enrollment period that begins October 1, 2013, and extends through March 31, 2014.
(b)
A carrier shall accept all applicants who apply for coverage during the initial open enrollment period.
(c)
If an application is received by a carrier during the initial open enrollment period, coverage for the applicant shall begin no later than:
(1)
January 1, 2014, if the application is received on or before December 15, 2013;
(2)
the first day of the following month, if the application is received between the first and fifteenth day, inclusive, of January, February, or March; and
(3)
the first day of the second following month, if the application is received between the sixteenth day and the last day, inclusive, of December, January, February, or March.
Md. Code Ann., Ins. § 15-1318 (2026)
Title 15. Health Insurance
Subtitle 13. Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms
§ 15–1318LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Institution of higher education” has the meaning stated in the federal Higher Education Act of 1965.
(3)
“Student administrative health fee” means a fee charged by an institution of higher education on a periodic basis to students of the institution of higher education to offset the cost of providing health care through health clinics regardless of whether the students utilize the health clinics or enroll in student health plan coverage.
(4)
“Student health plan” means an individual health benefit plan that is provided to students enrolled in an institution of higher education and their dependents under a written agreement that:
(i)
is between the institution of higher education and a carrier;
(ii)
does not make coverage under the health benefit plan available other than in connection with enrollment as a student or as a dependent of a student in the institution of higher education; and
(iii)
does not condition eligibility for the health benefit plan on any health status–related factor relating to a student or a dependent of a student.
(b)
A carrier that offers student health plans is not required to:
(1)
accept individuals who are not:
(i)
students; or
(ii)
dependents of students covered under the student health plan;
(2)
establish open enrollment periods;
(3)
establish effective dates that are based on a calendar year;
(4)
offer health benefit plan contracts that are on a calendar year basis; or
(5)
renew, or continue in force, coverage for individuals who are no longer students or dependents of students.
(c)
A student health plan is not subject to the requirement of a single risk pool under § 1312(c) of the Affordable Care Act.
(d)
A student health plan shall comply with the requirements of 45 C.F.R. § 147.145, as interpreted and implemented by the federal Centers for Medicare and Medicaid Services.
(e)
A student administrative health fee is not considered a cost–sharing requirement with respect to specified recommended preventive services.
Subtitle 14. Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms
Md. Code Ann., Ins. § 15-1401 (2026)
Title 15. Health Insurance
Subtitle 14. Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms
§ 15–1401LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Association” or “bona fide association” means, with respect to health insurance coverage offered in this State, an association that:
(1)
has been actively in existence for at least 5 years;
(2)
has been formed and maintained in good faith for purposes other than obtaining insurance and does not condition membership on the purchase of association–sponsored insurance;
(3)
does not condition membership in the association on any health status–related factor relating to an individual, and states so clearly in all membership and application materials;
(4)
makes health insurance coverage offered through the association available to all members regardless of any health status–related factor relating to the members or individuals eligible for coverage through a member and states so clearly in all membership and application materials;
(5)
does not make health insurance coverage offered through the association available other than in connection with membership in the association and states so clearly in all marketing and application materials; and
(6)
provides and annually updates information necessary for the Commissioner to determine whether or not the association meets the definition of bona fide association before qualifying as an association under this subtitle.
(c)
“Carrier” means a person that is:
(1)
an insurer that holds a certificate of authority in the State and provides health insurance in the State;
(2)
a health maintenance organization that is licensed to operate in the State;
(3)
a nonprofit health service plan that is licensed to operate in the State; or
(4)
any other person or organization that provides health benefit plans subject to State insurance regulation.
(d)
“Church plan” means a plan as defined under § 3(33) of the Employee Retirement Income Security Act of 1974.
(e)
“Employer sponsored plan” means an employee welfare benefit plan that provides medical care to employees or their dependents, and is not subject to State regulation in accordance with the federal Employee Retirement Income Security Act of 1974.
(f)
“Enrollment date” means the date on which:
(1)
an individual enrolls in a health benefit plan; or
(2)
the first day of the waiting period before which the individual may enroll.
(g)
“Governmental plan” means a plan as defined in § 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan.
(h)
(1)
“Health benefit plan” means any:
(i)
hospital or medical policy, including those issued under multiple employer trusts or associations located in Maryland or any other state covering Maryland residents;
(ii)
policy or contract issued by a nonprofit health service plan that covers Maryland residents; or
(iii)
health maintenance organization subscriber or group master contract.
(2)
“Health benefit plan” does not include:
(i)
one or more, or any combination of the following:
(1)
coverage only for accident or disability income insurance;
(2)
coverage issued as a supplement to liability insurance;
(3)
liability insurance, including general liability insurance and automobile liability insurance;
(4)
workers’ compensation or similar insurance;
(5)
automobile medical payment insurance;
(6)
credit–only insurance;
(7)
coverage for on–site medical clinics; and
(8)
other similar insurance coverage, specified in federal regulations issued under the federal Health Insurance Portability and Accountability Act, under which benefits for medical care are secondary or incidental to other insurance benefits;
(ii)
the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan:
(1)
limited scope dental or vision benefits;
(2)
benefits for long–term care, nursing home care, home health care, community–based care, or any combination of these benefits; and
(3)
such other similar, limited benefits as are specified in federal regulations issued under the federal Health Insurance Portability and Accountability Act;
(iii)
the following benefits if offered as independent, noncoordinated benefits:
(1)
coverage only for a specified disease or illness; and
(2)
hospital indemnity or other fixed indemnity insurance, if the benefits are payable in a fixed dollar amount per period of time, regardless of the amount of expenses incurred; or
(iv)
the following benefits if offered as a separate insurance policy:
(1)
Medicare supplemental health insurance (as defined under § 1882(g)(1) of the Social Security Act);
(2)
coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and
(3)
similar supplemental coverage provided to coverage under an employer sponsored plan if the coverage qualifies for the exception described in 45 C.F.R. § 146.145(b)(5)(i)(C).
(i)
“Health status–related factor” means a factor related to:
(1)
health status;
(2)
medical condition;
(3)
claims experience;
(4)
receipt of health care;
(5)
medical history;
(6)
genetic information;
(7)
evidence of insurability including conditions arising out of acts of domestic violence; or
(8)
disability.
(j)
“Late enrollee” means a member, subscriber, or dependent who enrolls in a group health benefit plan other than during:
(1)
the first period in which the individual is eligible to enroll under the plan; or
(2)
a special enrollment period.
(k)
“Preexisting condition” means a condition that was present before the date of enrollment for coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.
(l)
“Preexisting condition provision” means a provision in a health benefit plan that denies, excludes, or limits benefits for an enrollee for expenses or services related to a preexisting condition.
(m)
“Secretary” means the Secretary of the federal Department of Health and Human Services.
(n)
“Special enrollment period” means a period during which a group health plan shall permit certain individuals who are eligible for coverage, but not enrolled, to enroll for coverage under the terms of the group health benefit plan.
(o)
“Waiting period” means the period of time that must pass before an individual is eligible to be covered for benefits under the terms of a group health benefit plan.
Md. Code Ann., Ins. § 15-1402 (2026)
Title 15. Health Insurance
Subtitle 14. Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms
§ 15–1402LinkCopy Citation
(a)
Subject to subsection (b) of this section, this subtitle applies to all carriers in connection with group health benefit plans.
(b)
This subtitle does not apply to policies issued under Subtitle 12 of this title.
Md. Code Ann., Ins. § 15-1406 (2026)
Title 15. Health Insurance
Subtitle 14. Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms
§ 15–1406LinkCopy Citation
(a)
A carrier may not establish rules for eligibility of an individual to enroll under a group health benefit plan based on any health status-related factor.
(b)
Subsection (a) of this section does not:
(1)
require a carrier to provide particular benefits other than those provided under the terms of the particular health benefit plan; or
(2)
prevent a carrier from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled in the health benefit plan.
(c)
Rules for eligibility to enroll under a plan include rules defining any applicable waiting periods for enrollment.
(d)
A carrier shall allow an employee or dependent who is eligible, but not enrolled, for coverage under the terms of a group health benefit plan to enroll for coverage under the terms of the plan if:
(1)
the employee or dependent was covered under an employer-sponsored plan or group health benefit plan at the time coverage was previously offered to the employee or dependent;
(2)
the employee states in writing, at the time coverage was previously offered, that coverage under an employer-sponsored plan or group health benefit plan was the reason for declining enrollment, but only if the plan sponsor or issuer requires the statement and provides the employee with notice of the requirement;
(3)
the employee’s or dependent’s coverage described in item (1) of this subsection:
(i)
was under a COBRA continuation provision, and the coverage under that provision was exhausted; or
(ii)
was not under a COBRA continuation provision, and either the coverage was terminated as a result of loss of eligibility for the coverage, including loss of eligibility as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment, or employer contributions towards the coverage were terminated; and
(4)
under the terms of the plan, the employee requests enrollment not later than 30 days after:
(i)
the date of exhaustion of coverage described in item (3)(i) of this subsection; or
(ii)
termination of coverage or termination of employer contributions described in item (3)(ii) of this subsection.
Md. Code Ann., Ins. § 15-1406.1 (2026)
Title 15. Health Insurance
Subtitle 14. Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms
§ 15–1406.1LinkCopy Citation
(a)
In this section, “eligible employee” means:
(1)
a participant under the group health benefit plan; or
(2)
an individual who:
(i)
has met any waiting period applicable to becoming a participant under the group health benefit plan;
(ii)
is eligible to be enrolled under the plan; and
(iii)
is not a participant in the group health benefit plan because of failure to enroll during a previous enrollment period.
(b)
This section applies if a group health benefit plan makes coverage available to dependents of an eligible employee.
(c)
A group health benefit plan subject to this section shall provide a special enrollment period during which the following individuals may be enrolled under the group health benefit plan:
(1)
an individual who becomes a dependent of an eligible employee through marriage, birth, adoption, or placement for adoption;
(2)
an eligible employee who acquires a new dependent through marriage, birth, adoption, or placement for adoption; and
(3)
the spouse of an eligible employee at the birth or adoption of a child, provided the spouse is otherwise eligible for coverage.
(d)
An eligible employee may not enroll a dependent during a special enrollment period unless the eligible employee:
(1)
is enrolled under the health benefit plan; or
(2)
applies for coverage for the eligible employee during the same special enrollment period.
(e)
The special enrollment period under subsection (c) of this section shall be a period of not less than 31 days and shall begin on the later of:
(1)
the date dependent coverage is made available; or
(2)
the date of the marriage, birth, adoption, or placement for adoption, whichever is applicable.
(f)
If an eligible employee enrolls any of the individuals described in subsection (c) of this section during the first 31 days of the special enrollment period, the coverage shall become effective as follows:
(1)
in the case of marriage, not later than the first day of the first month beginning after the date the completed request for enrollment is received;
(2)
in the case of a dependent’s birth, as of the date of the dependent’s birth; and
(3)
in the case of a dependent’s adoption or placement for adoption, the date of adoption or placement for adoption, whichever occurs first.
Md. Code Ann., Ins. § 15-1407 (2026)
Title 15. Health Insurance
Subtitle 14. Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms
§ 15–1407LinkCopy Citation
A carrier may not require an individual member of a group to pay a premium or contribution that is greater than the premium or contribution for a similarly situated individual, based on any health status-related factor.
Md. Code Ann., Ins. § 15-1408 (2026)
Title 15. Health Insurance
Subtitle 14. Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms
§ 15–1408LinkCopy Citation
A carrier shall renew group health benefit plans at the option of the policyholder or plan sponsor, except in any of the following cases:
(1)
for nonpayment of the required premium;
(2)
where the policyholder or plan sponsor has performed an act or practice that constitutes fraud;
(3)
where the policyholder or plan sponsor has made an intentional misrepresentation of material fact under the terms of the coverage;
(4)
where the policyholder or plan sponsor has failed to comply with a material plan provision relating to the employer contributions or group participation rules;
(5)
where the carrier elects not to renew all group health benefit plans in the State;
(6)
in the case of a health maintenance organization, where there is no longer any enrollee who lives, resides, or works in the health maintenance organization’s approved service area, provided notice of the nonrenewal is provided to each employer and to each employee covered under the health benefit plan at least 90 days before the date coverage will be terminated;
(7)
in the case of a carrier that offers coverage only through one or more bona fide associations, when the membership of an employer in the association ceases and nonrenewal under this item is applied uniformly without regard to any health status–related factor relating to any covered individual; or
(8)
the carrier makes an election under § 15–1409 of this subtitle.
Md. Code Ann., Ins. § 15-1409 (2026)
Title 15. Health Insurance
Subtitle 14. Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms
§ 15–1409LinkCopy Citation
(a)
In this section, “product” means a discrete package of health benefits that are offered using a particular product network type within a geographic service area.
(b)
A carrier that elects not to renew all of a particular product in the State shall:
(1)
provide notice of the nonrenewal at least 90 days before the date of the nonrenewal to each affected:
(i)
policyholder;
(ii)
plan sponsor;
(iii)
participant; and
(iv)
beneficiary;
(2)
offer to each affected plan sponsor the option to purchase any other health insurance coverage currently being offered by the carrier; and
(3)
act uniformly without regard to the claims experience of any affected plan sponsor, or any health status–related factor of any affected individual.
(c)
A carrier may elect not to renew all group health benefit plans in the State.
(d)
When a carrier elects not to renew all group health benefit plans in the State, the carrier:
(1)
shall give notice of its decision to the affected individuals at least 180 days before the effective date of nonrenewal;
(2)
at least 30 working days before that notice, shall give notice to the Commissioner; and
(3)
may not write new business for groups in the State for a 5–year period beginning on the date of notice to the Commissioner.
(e)
A health maintenance organization need not offer coverage to an individual who does not live, reside, or work within the health maintenance organization’s approved service areas.
(f)
A carrier may make a uniform modification of coverage for a product only at the time of renewal of a health benefit plan.
(g)
A carrier will not be considered to have elected not to renew all group health benefit plans in the State if the carrier complies with 45 C.F.R. § 147.106(d)(3).
Md. Code Ann., Ins. § 15-1410 (2026)
Title 15. Health Insurance
Subtitle 14. Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms
§ 15–1410LinkCopy Citation
(a)
In this section, “plan year” has the meaning stated in § 15–1201 of this title.
(b)
The guaranteed issuance of coverage provision in Title I, Subtitle C of the Affordable Care Act applies to each health benefit plan with a plan year that begins on or after January 1, 2014.
Md. Code Ann., Ins. § 15-1411 (2026)
Title 15. Health Insurance
Subtitle 14. Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms
§ 15–1411LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Aggregate incurred claims” means the total claims incurred in the experience period that the carrier uses to experience rate a large employer’s health benefit plan.
(3)
“Experience rating” means that a carrier develops the premium rates for an employer’s health benefit plan based in whole or in part on the claims experience of the group that consists of the employer’s employees or employees’ dependents.
(4)
“Large employer” means an employer that is not a small employer as defined in § 31–101 of this article.
(b)
If a carrier is experience rating a large employer’s health benefit plan, the carrier shall disclose the aggregate incurred claims of the group to the large employer within 30 days after receipt of a request from the large employer.
(c)
The aggregate incurred claims required to be disclosed under subsection (b) of this section shall be provided in a format that complies with the privacy requirements of the federal Health Insurance Portability and Accessibility Act.
Subtitle 15. Mandated Health Insurance Services Evaluation
Md. Code Ann., Ins. § 15-1501 (2026)
Title 15. Health Insurance
Subtitle 15. Mandated Health Insurance Services Evaluation
§ 15–1501LinkCopy Citation
(a)
(1)
In this subtitle the following words have the meanings indicated.
(2)
“Commission” means the Maryland Health Care Commission.
(3)
(i)
“Mandated health insurance service” means a legislative proposal or statute that would require a particular health care service to be provided or offered in a health benefit plan, by a carrier, including a health maintenance organization, or other organization authorized to provide health benefit plans in the State.
(ii)
“Mandated health insurance service”, as applicable to all carriers, does not include services enumerated to describe a health maintenance organization under § 19–701(g)(2) of the Health – General Article.
(b)
This subtitle does not affect the ability of the General Assembly to enact legislation on mandated health insurance services.
(c)
(1)
The Commission shall assess the social, medical, and financial impacts of a proposed mandated health insurance service.
(2)
In assessing a proposed mandated health insurance service and to the extent that information is available, the Commission shall consider:
(i)
social impacts, including:
(1)
the extent to which the service is generally utilized by a significant portion of the population;
(2)
the extent to which the insurance coverage is already generally available;
(3)
if coverage is not generally available, the extent to which the lack of coverage results in individuals avoiding necessary health care treatments;
(4)
if coverage is not generally available, the extent to which the lack of coverage results in unreasonable financial hardship;
(5)
the level of public demand for the service;
(6)
the level of public demand for insurance coverage of the service;
(7)
the level of interest of collective bargaining agents in negotiating privately for inclusion of this coverage in group contracts; and
(8)
the extent to which the mandated health insurance service is covered by self–funded employer groups of employers in the State who employ at least 500 employees;
(ii)
medical impacts, including:
(1)
the extent to which the service is generally recognized by the medical community as being effective and efficacious in the treatment of patients;
(2)
the extent to which the service is generally recognized by the medical community as demonstrated by a review of scientific and peer review literature; and
(3)
the extent to which the service is generally available and utilized by treating physicians; and
(iii)
financial impacts, including:
(1)
the extent to which the coverage will increase or decrease the cost of the service;
(2)
the extent to which the coverage will increase the appropriate use of the service;
(3)
the extent to which the mandated service will be a substitute for a more expensive service;
(4)
the extent to which the coverage will increase or decrease the administrative expenses of carriers, including health maintenance organizations, or other organizations authorized to provide health benefit plans in the State, and the premium and administrative expenses of policy holders and contract holders;
(5)
the impact of this coverage on the total cost of health care; and
(6)
the impact of all mandated health insurance services on employers’ ability to purchase health benefits policies meeting their employees’ needs.
(d)
Subject to the limitations of the State budget, the Commission may contract for actuarial services and other professional services to carry out the provisions of this section.
(e)
(1)
On or before December 31, 1998, and each December 31 thereafter, the Commission shall submit a report on its findings, including any recommendations, to the Governor and, subject to § 2–1257 of the State Government Article, the General Assembly.
(2)
The annual report prepared by the Commission shall include an evaluation of any mandated health insurance service legislatively proposed or otherwise submitted to the Commission by a member of the General Assembly prior to July 1 of that year.
Md. Code Ann., Ins. § 15-1502 (2026)
Title 15. Health Insurance
Subtitle 15. Mandated Health Insurance Services Evaluation
§ 15–1502LinkCopy Citation
(a)
(1)
The Commission shall conduct an evaluation of existing mandated health insurance services and make recommendations to the General Assembly regarding decision making criteria for reducing the number of mandates or the extent of coverage.
(2)
The evaluation shall include:
(i)
an assessment of the full cost of each existing mandated health insurance service as a percentage of the State’s average annual wage and of premiums:
(1)
under a typical group and individual health benefit plan in the State;
(2)
under the State employee health benefit plan; and
(3)
under the Comprehensive Standard Health Benefit Plan;
(ii)
an assessment of the degree to which existing mandated health insurance services are covered in self–funded plans; and
(iii)
a comparison of mandated health insurance services provided by the State with those provided in Delaware, the District of Columbia, Pennsylvania, and Virginia.
(3)
The comparison described in paragraph (2)(iii) of this subsection shall include:
(i)
the number of mandated health insurance services;
(ii)
the type of mandated health insurance services;
(iii)
the level and extent of coverage for each mandated health insurance service; and
(iv)
the financial impact of differences in levels of coverage for each mandated health insurance service.
(4)
On or before January 1, 2004, and every 4 years thereafter, the Commission shall submit a report of its findings to the General Assembly, subject to § 2–1257 of the State Government Article.
(b)
The General Assembly may consider the information provided under subsection (a) of this section in determining:
(1)
whether to enact proposed mandated health insurance services; and
(2)
whether to repeal existing mandated health insurance services.
Subtitle 16. Pharmacy Benefits Managers
Md. Code Ann., Ins. § 15-1601 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1601LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Agent” means a pharmacy, a pharmacist, a mail order pharmacy, or a nonresident pharmacy acting on behalf or at the direction of a pharmacy benefits manager.
(c)
“Beneficiary” means an individual who receives prescription drug coverage or benefits from a purchaser.
(d)
(1)
“Carrier” means the State Employee and Retiree Health and Welfare Benefits Program, an insurer, a nonprofit health service plan, or a health maintenance organization that:
(i)
provides prescription drug coverage or benefits in the State; and
(ii)
enters into an agreement with a pharmacy benefits manager for the provision of pharmacy benefits management services.
(2)
“Carrier” does not include a person that provides prescription drug coverage or benefits through plans subject to ERISA and does not provide prescription drug coverage or benefits through insurance, unless the person is a multiple employer welfare arrangement as defined in § 514(b)(6)(a)(ii) of ERISA.
(e)
“Compensation program” means a program, policy, or process through which sources and pricing information are used by a pharmacy benefits manager to determine the terms of payment as stated in a participating pharmacy contract.
(f)
“Contracted pharmacy” means a pharmacy that participates in the network of a pharmacy benefits manager through a contract with:
(1)
the pharmacy benefits manager; or
(2)
a pharmacy services administration organization or a group purchasing organization.
(g)
“ERISA” has the meaning stated in § 8–301 of this article.
(h)
“Formulary” means a list of prescription drugs used by a purchaser.
(i)
(1)
“Manufacturer payments” means any compensation or remuneration a pharmacy benefits manager receives from or on behalf of a pharmaceutical manufacturer.
(2)
“Manufacturer payments” includes:
(i)
payments received in accordance with agreements with pharmaceutical manufacturers for formulary placement and, if applicable, drug utilization;
(ii)
rebates, regardless of how categorized;
(iii)
market share incentives;
(iv)
commissions;
(v)
fees under products and services agreements;
(vi)
any fees received for the sale of utilization data to a pharmaceutical manufacturer; and
(vii)
administrative or management fees.
(3)
“Manufacturer payments” does not include purchase discounts based on invoiced purchase terms.
(j)
“Nonprofit health maintenance organization” has the meaning stated in § 6–121(a) of this article.
(k)
“Nonresident pharmacy” has the meaning stated in § 12–403 of the Health Occupations Article.
(l)
“Participating pharmacy contract” means a contract filed with the Commissioner in accordance with § 15–1628(b) of this subtitle.
(m)
“Pharmacist” has the meaning stated in § 12–101 of the Health Occupations Article.
(n)
“Pharmacy” has the meaning stated in § 12–101 of the Health Occupations Article.
(o)
“Pharmacy and therapeutics committee” means a committee established by a pharmacy benefits manager to:
(1)
objectively appraise and evaluate prescription drugs; and
(2)
make recommendations to a purchaser regarding the selection of drugs for the purchaser’s formulary.
(p)
(1)
“Pharmacy benefits management services” means:
(i)
the procurement of prescription drugs at a negotiated rate for dispensation within the State to beneficiaries;
(ii)
the administration or management of prescription drug coverage provided by a purchaser for beneficiaries; and
(iii)
any of the following services provided with regard to the administration of prescription drug coverage:
(1)
mail service pharmacy;
(2)
claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to beneficiaries;
(3)
clinical formulary development and management services;
(4)
rebate contracting and administration;
(5)
patient compliance, therapeutic intervention, and generic substitution programs; or
(6)
disease management programs.
(2)
“Pharmacy benefits management services” does not include any service provided by a nonprofit health maintenance organization that operates as a group model, provided that the service:
(i)
is provided solely to a member of the nonprofit health maintenance organization; and
(ii)
is furnished through the internal pharmacy operations of the nonprofit health maintenance organization.
(q)
“Pharmacy benefits manager” means a person that performs pharmacy benefits management services.
(r)
“Proprietary information” means:
(1)
a trade secret;
(2)
confidential commercial information; or
(3)
confidential financial information.
(s)
“Purchaser” means a person that offers a plan or program in the State, including the State Employee and Retiree Health and Welfare Benefits Program, that:
(1)
provides prescription drug coverage or benefits in the State; and
(2)
enters into an agreement with a pharmacy benefits manager for the provision of pharmacy benefits management services.
(t)
“Rebate sharing contract” means a contract between a pharmacy benefits manager and a purchaser under which the pharmacy benefits manager agrees to share manufacturer payments with the purchaser.
(u)
(1)
“Therapeutic interchange” means any change from one prescription drug to another.
(2)
“Therapeutic interchange” does not include:
(i)
a change initiated pursuant to a drug utilization review;
(ii)
a change initiated for patient safety reasons;
(iii)
a change required due to market unavailability of the currently prescribed drug;
(iv)
a change from a brand name drug to a generic drug in accordance with § 12–504 of the Health Occupations Article; or
(v)
a change required for coverage reasons because the originally prescribed drug is not covered by the beneficiary’s formulary or plan.
(v)
“Therapeutic interchange solicitation” means any communication by a pharmacy benefits manager for the purpose of requesting a therapeutic interchange.
(w)
“Trade secret” has the meaning stated in § 11–1201 of the Commercial Law Article.
Md. Code Ann., Ins. § 15-1604 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1604LinkCopy Citation
(a)
A pharmacy benefits manager shall register with the Commissioner as a pharmacy benefits manager before providing pharmacy benefits management services in the State to purchasers.
(b)
An applicant for registration shall:
(1)
file with the Commissioner an application on the form that the Commissioner provides; and
(2)
pay to the Commissioner a registration fee set by the Commissioner.
(c)
The Commissioner may require any additional information or submissions from a pharmacy benefits manager that may be reasonably necessary to verify the information contained in the application.
(d)
Subject to the provisions of § 15–1607 of this part, the Commissioner shall register each pharmacy benefits manager that meets the requirements of this section.
Md. Code Ann., Ins. § 15-1605 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1605LinkCopy Citation
(a)
A pharmacy benefits manager registration expires on the second September 30 after its effective date unless it is renewed as provided under this section.
(b)
A pharmacy benefits manager may renew its registration for an additional 2–year term, if the pharmacy benefits manager:
(1)
otherwise is entitled to be registered;
(2)
files with the Commissioner a renewal application on the form that the Commissioner requires; and
(3)
pays to the Commissioner a renewal fee set by the Commissioner.
(c)
An application for renewal of a pharmacy benefits manager registration shall be considered made in a timely manner if it is postmarked on or before the date the pharmacy benefits manager’s registration expires.
(d)
Subject to the provisions of § 15–1607 of this part, the Commissioner shall renew the registration of each pharmacy benefits manager that meets the requirements of this section.
(e)
The Commissioner may require any additional information or submissions from a pharmacy benefits manager that may be reasonably necessary to verify the information contained in the application.
Md. Code Ann., Ins. § 15-1606 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1606LinkCopy Citation
A carrier may not enter into an agreement with a pharmacy benefits manager that has not registered with the Commissioner.
Md. Code Ann., Ins. § 15-1607 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1607LinkCopy Citation
(a)
Subject to the applicable hearing provisions of Title 2 of this article, the Commissioner may deny a registration to a pharmacy benefits manager applicant or refuse to renew, suspend, or revoke the registration of a pharmacy benefits manager if the pharmacy benefits manager, or an officer, director, or employee of the pharmacy benefits manager:
(1)
makes a material misstatement or misrepresentation in an application for registration;
(2)
fraudulently or deceptively obtains or attempts to obtain a registration;
(3)
in connection with the administration of pharmacy benefits management services, commits fraud or engages in illegal or dishonest activities; or
(4)
violates any provision of this part or a regulation adopted under this part.
(b)
This section does not limit any other regulatory authority of the Commissioner under this article.
Md. Code Ann., Ins. § 15-1608 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1608LinkCopy Citation
A pharmacy benefits manager shall maintain adequate books and records about each purchaser for which the pharmacy benefits manager provides pharmacy benefits management services:
(1)
in accordance with prudent standards of record keeping;
(2)
for the duration of the agreement between the pharmacy benefits manager and the purchaser; and
(3)
for 3 years after the pharmacy benefits manager ceases to provide pharmacy benefits management services for the purchaser.
Md. Code Ann., Ins. § 15-1609 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1609LinkCopy Citation
(a)
Whenever the Commissioner considers it advisable, the Commissioner may examine the affairs, transactions, accounts, and records of a registered pharmacy benefits manager.
(b)
The examination shall be conducted in accordance with § 2–207 of this article.
(c)
The expense of the examination shall be paid in accordance with § 2–208 of this article.
(d)
The reports of the examination and investigation shall be issued in accordance with § 2–209 of this article.
Md. Code Ann., Ins. § 15-1610 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1610LinkCopy Citation
A pharmacy benefits manager may not ship, mail, or deliver prescription drugs or devices to a person in the State through a nonresident pharmacy unless the nonresident pharmacy holds a permit issued in accordance with the provisions of § 12–403 of the Health Occupations Article.
Md. Code Ann., Ins. § 15-1611 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1611LinkCopy Citation
(a)
This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)
A pharmacy benefits manager may not prohibit a pharmacy or pharmacist from:
(1)
providing a beneficiary with information regarding the retail price for a prescription drug or the amount of the cost share for which the beneficiary is responsible for a prescription drug;
(2)
discussing with a beneficiary information regarding the retail price for a prescription drug or the amount of the cost share for which the beneficiary is responsible for a prescription drug; or
(3)
if a more affordable drug is available than one on the purchaser’s formulary and the requirements for a therapeutic interchange under §§ 15–1633.1 through 15–1639 of this subtitle are met, selling the more affordable alternative to the beneficiary.
(c)
This section may not be construed to alter the requirements for a therapeutic interchange under §§ 15–1633.1 through 15–1639 of this subtitle.
Md. Code Ann., Ins. § 15-1611.1 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1611.1LinkCopy Citation
(a)
This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)
Except as provided in subsection (c) of this section, a pharmacy benefits manager may not require that a beneficiary use a specific pharmacy or entity to fill a prescription if:
(1)
the pharmacy benefits manager or a corporate affiliate of the pharmacy benefits manager has an ownership interest in the pharmacy or entity; or
(2)
the pharmacy or entity has an ownership interest in the pharmacy benefits manager or a corporate affiliate of the pharmacy benefits manager.
(c)
Except as provided in § 15–847.2 of this title, a pharmacy benefits manager may require a beneficiary to use a specific pharmacy or entity for a specialty drug as defined in § 15–847 of this title.
Md. Code Ann., Ins. § 15-1611.2 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1611.2LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Covered entity” has the meaning stated in § 602 of the federal Veterans Health Care Act of 1992.
(3)
“Pharmacies or pharmacists that participate in the 340B Program” means:
(i)
a pharmacy owned or operated by a covered entity that is eligible to or is actively participating in the 340B Program; or
(ii)
a pharmacy or pharmacist under contract with a covered entity to dispense drugs purchased under the 340B Program to patients of the covered entity.
(4)
“340B Program” means the drug pricing program established under § 602 of the federal Veterans Health Care Act of 1992.
(b)
A pharmacy benefits manager shall:
(1)
make formulary and coverage decisions for a pharmacy or pharmacist that participates in the 340B Program based on the normal course of business of the pharmacy benefits manager; and
(2)
allow a beneficiary to use any in–network pharmacy or pharmacist that the beneficiary choses, without regard to whether the pharmacy or pharmacist participates in the 340B Program.
(c)
A pharmacy benefits manager may not:
(1)
transfer the 340B Program savings from a pharmacy or pharmacist that participates in the 340B Program to a pharmacy benefits manager;
(2)
offer lower reimbursement for a prescription drug purchased under the 340B Program than the reimbursement it offers for the same prescription drug if it is not purchased under the 340B Program;
(3)
refuse to cover the prescription drugs purchased under the 340B Program;
(4)
refuse to allow pharmacies or pharmacists that participate in the 340B Program to participate in the pharmacy benefits manager’s network on the sole basis that the pharmacy or pharmacist participates in the 340B Program;
(5)
impose different reimbursement or network participation contract terms on pharmacies or pharmacists that participate in a pharmacy benefits manager’s network based on whether a pharmacy or pharmacist participates in the 340B Program;
(6)
impose different fees, chargebacks, or other adjustments on pharmacies or pharmacists based on whether a pharmacy or pharmacist participates in the 340B Program;
(7)
modify a beneficiary’s copayment on the basis of whether a pharmacy or pharmacist participates in the 340B Program;
(8)
establish or set network adequacy requirements based on whether a pharmacy or pharmacist participates in the 340B Program; or
(9)
prohibit a covered entity authorized to participate in the 340B Program or a pharmacy or pharmacist under contract with a covered entity authorized to participate in the 340B Program from participating in the pharmacy benefits manager’s network on the basis of the covered entity’s participation in the 340B Program.
(d)
A pharmacy benefits manager may not base formulary or prescription drug coverage decisions on:
(1)
the price of the prescription drug under the 340B Program; or
(2)
whether the dispensing pharmacy or pharmacist participates in the 340B Program.
Md. Code Ann., Ins. § 15-1612 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1612LinkCopy Citation
(a)
This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)
This section does not apply to reimbursement:
(1)
except as provided in § 15–847.2 of this title, for specialty drugs;
(2)
for mail order drugs; or
(3)
to a chain pharmacy with more than 15 stores or a pharmacist who is an employee of the chain pharmacy.
(c)
A pharmacy benefits manager may not reimburse a pharmacy or pharmacist for a pharmaceutical product or pharmacist service in an amount less than the amount that the pharmacy benefits manager reimburses itself or an affiliate for providing the same product or service.
Md. Code Ann., Ins. § 15-1613 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1613LinkCopy Citation
A pharmacy and therapeutics committee established by a pharmacy benefits manager performing pharmacy benefits management services on behalf of a carrier shall meet the requirements of this part.
Md. Code Ann., Ins. § 15-1614 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1614LinkCopy Citation
(a)
(1)
A pharmacy and therapeutics committee shall:
(i)
include clinical specialists that represent the needs of a purchaser’s beneficiaries; and
(ii)
include at least one practicing pharmacist and one practicing physician who are independent of any developer or manufacturer of prescription drugs.
(2)
A majority of the members of a pharmacy and therapeutics committee shall be practicing physicians or practicing pharmacists.
(b)
Each member of a pharmacy and therapeutics committee shall sign a conflict of interest statement updated at least annually disclosing any economic interest or relationship that could influence the pharmacy and therapeutics committee’s decisions.
Md. Code Ann., Ins. § 15-1615 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1615LinkCopy Citation
A pharmacy benefits manager may not require a pharmacist to participate on its pharmacy and therapeutics committee.
Md. Code Ann., Ins. § 15-1616 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1616LinkCopy Citation
On request of a purchaser for which the pharmacy and therapeutics committee makes recommendations, a pharmacy benefits manager shall disclose information about the composition of its pharmacy and therapeutics committee to the purchaser.
Md. Code Ann., Ins. § 15-1617 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1617LinkCopy Citation
A pharmacy benefits manager shall ensure that its pharmacy and therapeutics committee has:
(1)
policies and procedures, including disclosure requirements, to address potential conflicts of interest that members of the pharmacy and therapeutics committee may have with developers or manufacturers of prescription drugs;
(2)
a process to evaluate medical and scientific evidence concerning the safety and effectiveness of prescription drugs, including available comparative information on clinically similar prescription drugs, when deciding what prescription drugs to recommend to include on a formulary;
(3)
a process to evaluate medical and scientific evidence concerning the safety and effectiveness of prescription drugs when recommending utilization review requirements, dose restrictions, and step therapy requirements; and
(4)
a process to enable the pharmacy and therapeutics committee to consider the need to recommend a formulary change to a purchaser in a timely manner but at least annually.
Md. Code Ann., Ins. § 15-1618 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1618LinkCopy Citation
The Commissioner may consider a pharmacy and therapeutics committee of a pharmacy benefits manager as having met the requirements of §§ 15–1614 and 15–1617 of this part if the pharmacy benefits manager has obtained accreditation from an accrediting organization approved by the Commissioner.
Md. Code Ann., Ins. § 15-1619 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1619LinkCopy Citation
The Commissioner may adopt regulations to implement this part.
Md. Code Ann., Ins. § 15-1622 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1622LinkCopy Citation
(a)
Except as provided for in subsection (b) of this section, the provisions of §§ 15–1623 and 15–1624 of this subtitle apply only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)
The provisions of §§ 15–1623 and 15–1624 of this subtitle do not apply to a pharmacy benefits manager when providing pharmacy benefits management services to a purchaser that is affiliated with the pharmacy benefits manager through common ownership within an insurance holding company.
Md. Code Ann., Ins. § 15-1623 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1623LinkCopy Citation
(a)
Before entering into a contract with a purchaser, a pharmacy benefits manager:
(1)
as applicable, shall inform the purchaser that the pharmacy benefits manager may:
(i)
solicit and receive manufacturer payments;
(ii)
pass through or retain the manufacturer payments depending on the contract terms with a purchaser;
(iii)
sell aggregate utilization information; and
(iv)
share aggregate utilization information with other entities; and
(2)
shall offer to provide to the purchaser a report that contains the:
(i)
net revenue of the pharmacy benefits manager from sales of prescription drugs to purchasers made through the pharmacy benefits manager’s network of contractually affiliated retail pharmacies or through the pharmacy benefits manager’s mail order pharmacies, with respect to the pharmacy benefits manager’s entire client base of purchasers; and
(ii)
amount of all manufacturer payments earned by the pharmacy benefits manager.
(b)
(1)
If a purchaser requests the information described in subsection (a)(2) of this section, a pharmacy benefits manager shall provide the information before entering into a contract with the purchaser.
(2)
Notwithstanding the provisions of paragraph (1) of this subsection, if a pharmacy benefits manager requires a nondisclosure agreement under which a purchaser agrees that the information described in subsection (a)(2) of this section is proprietary information, the pharmacy benefits manager may not be required to provide the information until the purchaser has signed the nondisclosure agreement.
Md. Code Ann., Ins. § 15-1624 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1624LinkCopy Citation
(a)
If a purchaser has a rebate sharing contract, a pharmacy benefits manager shall offer to provide the purchaser a report for each fiscal quarter and each fiscal year that contains the amount of the:
(1)
net revenue of the pharmacy benefits manager from sales of prescription drugs to purchasers made through the pharmacy benefits manager’s network of contractually affiliated retail pharmacies or through the pharmacy benefits manager’s mail order pharmacies, with respect to the pharmacy benefits manager’s entire client base of purchasers;
(2)
total prescription drug expenditures applicable to the purchaser;
(3)
total manufacturer payments earned by the pharmacy benefits manager during the applicable reporting period; and
(4)
total rebates applicable to the purchaser during the applicable reporting period.
(b)
If the exact amount of each item to be reported under subsection (a) of this section is not known by the pharmacy benefits manager at the time of its report, the pharmacy benefits manager shall offer to provide:
(1)
its current best estimate of the amount of each item; and
(2)
an updated report containing the exact amount of each item immediately after it becomes available.
(c)
(1)
A pharmacy benefits manager shall provide the information described in subsections (a) and (b) of this section if requested by the purchaser.
(2)
Notwithstanding the provisions of paragraph (1) of this subsection, if a pharmacy benefits manager requires a nondisclosure agreement under which a purchaser agrees that the information in subsections (a) and (b) of this section is proprietary information, the pharmacy benefits manager may not be required to provide the information until the purchaser has signed the nondisclosure agreement.
Md. Code Ann., Ins. § 15-1625 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1625LinkCopy Citation
This part does not diminish the authority of the Office of the Attorney General or the Commissioner to obtain information relating to a pharmacy benefits manager and use the information in any proceeding.
Md. Code Ann., Ins. § 15-1628 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1628LinkCopy Citation
(a)
(1)
At the time of entering into a contract with a pharmacy or a pharmacist, and at least 30 working days before any contract change, a pharmacy benefits manager shall disclose to the pharmacy or pharmacist:
(i)
the applicable terms, conditions, and reimbursement rates;
(ii)
the process and procedures for verifying pharmacy benefits and beneficiary eligibility;
(iii)
the dispute resolution and audit appeals process; and
(iv)
the process and procedures for verifying the prescription drugs included on the formularies used by the pharmacy benefits manager.
(2)
(i)
This paragraph does not apply to a requirement that a specialty pharmacy obtain national certification to be considered a specialty pharmacy in a pharmacy benefits manager’s or carrier’s network.
(ii)
For purposes of credentialing a pharmacy or a pharmacist as a condition for participating in a pharmacy benefits manager’s network for a carrier, the pharmacy benefits manager may not:
(1)
require a pharmacy or pharmacist to renew credentialing more frequently than once every 3 years; or
(2)
charge a pharmacy or pharmacist a fee for the initial credentialing or renewing credentialing.
(b)
(1)
Each contract form or an amendment to a contract form between a pharmacy benefits manager and a pharmacy or a pharmacy services administrative organization, as defined in § 15–2001 of this title, acting on behalf of a pharmacy may not become effective unless at least 30 days before the contract form or amendment to the contract form is to become effective, the pharmacy benefits manager files an informational filing with the Commissioner in the manner required by the Commissioner that includes a copy of the contract form or amendment to the contract form.
(2)
The Commissioner is not required to review the informational filing to evaluate whether a contract form or amendment to a contract form is in violation of this subtitle at the time the informational filing is made.
(3)
The Commissioner may review and disapprove a contract form or amendment to a contract form at any time after the contract form or amendment to the contract form has been submitted as part of an informational filing.
Md. Code Ann., Ins. § 15-1628.1 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1628.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Drug shortage list” means a list of drug products listed on the federal Food and Drug Administration’s Drug Shortages website.
(3)
(i)
“Maximum allowable cost” means the maximum amount that a pharmacy benefits manager or a purchaser will reimburse a contracted pharmacy for the cost of a multisource generic drug, a medical product, or a device.
(ii)
“Maximum allowable cost” does not include dispensing fees.
(4)
“Maximum allowable cost list” means a list of multisource generic drugs, medical products, and devices for which a maximum allowable cost has been established by a pharmacy benefits manager or a purchaser.
(b)
In each participating pharmacy contract, the pharmacy benefits manager shall include the sources used to determine maximum allowable cost pricing.
(c)
A pharmacy benefits manager shall:
(1)
update its pricing information at least every 7 days;
(2)
establish a reasonable process by which a contracted pharmacy has access to the current and applicable maximum allowable cost price lists in an electronic format as updated in accordance with the requirements of this section; and
(3)
immediately after a pricing information update under item (1) of this subsection, use the updated pricing information in calculating the payments made to all contracted pharmacies.
(d)
(1)
A pharmacy benefits manager shall maintain a procedure to eliminate products from the list of drugs subject to maximum allowable cost pricing as necessary to:
(i)
remain consistent with pricing changes;
(ii)
remove from the list drugs that no longer meet the requirements of subsection (e) of this section; and
(iii)
reflect the current availability of drugs in the marketplace.
(2)
A product on the maximum allowable cost list shall be eliminated from the list by the pharmacy benefits manager within 7 days after the pharmacy benefits manager knows of a change in the availability of the product.
(e)
Before placing a prescription drug on a maximum allowable cost list, a pharmacy benefits manager shall ensure that:
(1)
the drug is listed as “A” or “B” rated in the most recent version of the U.S. Food and Drug Administration’s approved drug products with therapeutic equivalence evaluations, also known as the Orange Book, or has an “NR” or “NA” rating or similar rating by a nationally recognized reference;
(2)
(i)
if a drug is manufactured by more than one manufacturer, the drug is generally available for purchase by contracted pharmacies, including contracted retail pharmacies, in the State from a wholesale distributor with a permit in the State; or
(ii)
if a drug is manufactured by only one manufacturer, the drug is generally available for purchase by contracted pharmacies, including contracted retail pharmacies, in the State from at least two wholesale distributors with a permit in the State; and
(3)
the drug is not obsolete, temporarily unavailable, or listed on a drug shortage list as currently in shortage.
(f)
For disputes regarding maximum allowable cost pricing, each participating pharmacy contract must include a process to appeal, investigate, and resolve disputes regarding maximum allowable cost pricing that includes:
(1)
a requirement that an appeal be filed by the contract pharmacy no later than 21 days after the date of the initial adjudicated claim;
(2)
a requirement that, within 21 days after the date the appeal is filed, the pharmacy benefits manager investigate and resolve the appeal and report to the contracted pharmacy on the pharmacy benefits manager’s determination on the appeal;
(3)
a requirement that a pharmacy benefits manager make available on its website information about the appeal process, including:
(i)
a telephone number at which the contracted pharmacy may directly contact the department or office responsible for processing appeals for the pharmacy benefits manager to speak to an individual or leave a message for an individual who is responsible for processing appeals;
(ii)
an e–mail address of the department or office responsible for processing appeals to which an individual who is responsible for processing appeals has access; and
(iii)
a notice indicating that the individual responsible for processing appeals shall return a call or an e–mail made by a contracted pharmacy to the individual within 3 business days or less of receiving the call or e–mail;
(4)
a requirement that a pharmacy benefits manager provide:
(i)
a reason for any appeal denial;
(ii)
the national drug code of a drug and the name of the wholesale distributor from which the drug was available on the date the claim was adjudicated at a price at or below the maximum allowable cost determined by the pharmacy benefits manager; and
(iii)
the mathematical calculation used to determine the maximum allowable cost; and
(5)
if an appeal is upheld, a requirement that a pharmacy benefits manager:
(i)
for the appealing pharmacy:
(1)
adjust the maximum allowable cost for the drug as of the date of the original claim for payment; and
(2)
without requiring the appealing pharmacy to reverse and rebill the claims, provide reimbursement for the claim and any subsequent and similar claims under similarly applicable contracts with the pharmacy benefits manager:
(A)
for the original claim, in the first remittance to the pharmacy after the date the appeal was determined; and
(B)
for subsequent and similar claims under similarly applicable contracts, in the second remittance to the pharmacy after the date the appeal was determined; and
(ii)
for a similarly situated contracted pharmacy in the State:
(1)
adjust the maximum allowable cost for the drug as of the date the appeal was determined; and
(2)
provide notice to the pharmacy or pharmacy’s contracted agent that:
(A)
an appeal has been upheld; and
(B)
without filing a separate appeal, the pharmacy or the pharmacy’s contracted agent may reverse and rebill a similar claim.
(g)
A pharmacy benefits manager may not retaliate against a contracted pharmacy for exercising its right to appeal under this section or filing a complaint with the Commissioner under this subsection.
(h)
A pharmacy benefits manager may not charge a contracted pharmacy a fee related to the readjudication of a claim or claims resulting from carrying out the requirement of a contract specified in subsection (f)(5) of this section or the upholding of an appeal under subsection (i) of this section.
(i)
(1)
If a pharmacy benefits manager denies an appeal and a contracted pharmacy or a designee of the contracted pharmacy files a complaint with the Commissioner, the Commissioner shall:
(i)
review the compensation program of the pharmacy benefits manager to ensure that the reimbursement for pharmacy benefits management services paid to the pharmacist or a pharmacy complies with this subtitle and the terms of the participating pharmacy contract; and
(ii)
based on a determination made by the Commissioner under item (i) of this paragraph, dismiss the appeal or uphold the appeal and order the pharmacy benefits manager to pay the claim or claims in accordance with the Commissioner’s findings.
(2)
On request, the pharmacy benefits manager shall provide to the Commissioner all mathematical calculations, accounts, records, documents, files, logs, correspondence, or other information necessary to complete the Commissioner’s review under paragraph (1) of this subsection.
(3)
All information and data collected by the Commissioner during a review:
(i)
is considered to be confidential and proprietary information; and
(ii)
is not subject to disclosure under the Public Information Act.
Md. Code Ann., Ins. § 15-1628.2 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1628.2LinkCopy Citation
(a)
For disputes regarding cost pricing and reimbursement under a participating pharmacy contract, each participating pharmacy contract must include a process to appeal, investigate, and resolve disputes regarding cost pricing and reimbursement that includes:
(1)
a requirement that an appeal be filed by the contract pharmacy not later than 21 days after:
(i)
the date a direct or indirect remuneration fee is charged; or
(ii)
another date as determined by the Commissioner;
(2)
a requirement that a pharmacy benefits manager make available on its website information about the appeal process, including:
(i)
a telephone number at which the contracted pharmacy may directly contact the department or office responsible for processing appeals for the pharmacy benefits manager to speak to an individual or leave a message for an individual who is responsible for processing appeals;
(ii)
an e–mail address of the department or office responsible for processing appeals to which an individual who is responsible for processing appeals has access; and
(iii)
a notice indicating that the individual responsible for processing appeals shall return a call or an e–mail made by a contracted pharmacy to the individual within 3 business days or less after receiving the call or e–mail;
(3)
a requirement that a pharmacy benefits manager provide:
(i)
a reason for any appeal denial; and
(ii)
the mathematical calculation used to determine the amount of reimbursement; and
(4)
if an appeal is upheld, a requirement that a pharmacy benefits manager:
(i)
make adjustments as necessary to comply with the compensation program as stated in the participating pharmacy contract as of the date the appeal was determined; and
(ii)
provide notice to the pharmacy or pharmacy’s contracted agent that an appeal has been upheld.
(b)
A pharmacy benefits manager may not retaliate against a contracted pharmacy for exercising its right to appeal under this section or filing a complaint with the Commissioner under this section.
(c)
A pharmacy benefits manager may not charge a contracted pharmacy a fee related to the readjudication of a claim or claims resulting from the upholding of an appeal under subsection (d) of this section.
(d)
(1)
If a pharmacy benefits manager denies an appeal and a contracted pharmacy or a designee of the contracted pharmacy files a complaint with the Commissioner, the Commissioner shall:
(i)
review the compensation program of the pharmacy benefits manager to ensure that the reimbursement for pharmacy services paid to the pharmacist or a pharmacy complies with this subtitle and the terms of the participating pharmacy contract; and
(ii)
based on a determination made by the Commissioner under item (i) of this paragraph, dismiss the appeal or uphold the appeal and order the pharmacy benefits manager to pay the claim or claims in accordance with the Commissioner’s findings.
(2)
On request, the pharmacy benefits manager shall provide to the Commissioner all mathematical calculations, accounts, records, documents, files, logs, correspondence, or other information necessary to complete the Commissioner’s review.
(3)
All information and data collected by the Commissioner during a review:
(i)
is considered to be confidential and proprietary information; and
(ii)
is not subject to disclosure under the Public Information Act.
Md. Code Ann., Ins. § 15-1628.3 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1628.3LinkCopy Citation
(a)
A pharmacy benefits manager or a carrier may not directly or indirectly charge a contracted pharmacy, or hold a contracted pharmacy responsible for, a fee or performance–based reimbursement related to the adjudication of a claim or an incentive program.
(b)
A pharmacy benefits manager or carrier may not make or allow any reduction in payment for pharmacy services by a pharmacy benefits manager or carrier or directly or indirectly reduce a payment for a pharmacy service under a reconciliation process to an effective rate of reimbursement, including generic effective rates, brand effective rates, direct and indirect remuneration fees, or any other reduction or aggregate reduction of payments.
Md. Code Ann., Ins. § 15-1629 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1629LinkCopy Citation
(a)
This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)
This section does not apply to an audit that involves probable or potential fraud or willful misrepresentation by a pharmacy or pharmacist.
(c)
A pharmacy benefits manager shall conduct an audit of a pharmacy or pharmacist under contract with the pharmacy benefits manager in accordance with this section.
(d)
(1)
A pharmacy benefits manager may conduct an audit through an auditing entity.
(2)
The Commissioner may adopt regulations to carry out this subsection.
(e)
A pharmacy benefits manager may not schedule an onsite audit to begin during the first 5 calendar days of a month unless requested by the pharmacy or pharmacist.
(f)
When conducting an audit, a pharmacy benefits manager shall:
(1)
if the audit is onsite, provide written notice to the pharmacy or pharmacist at least 2 weeks before conducting the initial onsite audit for each audit cycle;
(2)
employ the services of a pharmacist if the audit requires the clinical or professional judgment of a pharmacist;
(3)
allow its auditors to enter the prescription area of a pharmacy only when accompanied by or authorized by a member of the pharmacy staff;
(4)
allow a pharmacist or pharmacy to use any prescription, or authorized change to a prescription, that meets the requirements of COMAR 10.34.20.02 to validate claims submitted for reimbursement for dispensing of original and refill prescriptions;
(5)
for purposes of validating the pharmacy record with respect to orders or refills of a drug, allow the pharmacy or pharmacist to use records of a hospital or a physician or other prescriber authorized by law that are:
(i)
written; or
(ii)
transmitted electronically or by any other means of communication authorized by contract between the pharmacy and the pharmacy benefits manager;
(6)
accept a completed cash register transaction to serve as proof of delivery or pickup for a pharmacy customer unless there is contradictory information;
(7)
audit each pharmacy and pharmacist under the same standards and parameters as other similarly situated pharmacies or pharmacists audited by the pharmacy benefits manager;
(8)
only audit claims submitted or adjudicated within the 2–year period immediately preceding the audit, unless a longer period is authorized under federal or State law;
(9)
deliver the preliminary audit report to the pharmacy or pharmacist within 120 calendar days after the completion of the audit, with reasonable extensions allowed;
(10)
in accordance with subsection (m) of this section, allow a pharmacy or pharmacist to produce documentation to address any discrepancy found during the audit; and
(11)
deliver the final audit report to the pharmacy or pharmacist:
(i)
within 6 months after delivery of the preliminary audit report if the pharmacy or pharmacist does not request an internal appeal under subsection (m) of this section; or
(ii)
within 30 days after the conclusion of the internal appeals process under subsection (m) of this section if the pharmacy or pharmacist requests an internal appeal.
(g)
If a contract between a pharmacy or pharmacist and a pharmacy benefits manager specifies a period of time in which a pharmacy or pharmacist is allowed to withdraw and resubmit a claim and that period of time expires before the pharmacy benefits manager delivers a preliminary audit report that identifies discrepancies, the pharmacy benefits manager shall allow the pharmacy or pharmacist to withdraw and resubmit a claim within 30 days after:
(1)
the preliminary audit report is delivered if the pharmacy or pharmacist does not request an internal appeal under subsection (m) of this section; or
(2)
the conclusion of the internal appeals process under subsection (m) of this section if the pharmacy or pharmacist requests an internal appeal.
(h)
During an audit, a pharmacy benefits manager may not disrupt the provision of services to the customers of a pharmacy.
(i)
(1)
A pharmacy benefits manager may not:
(i)
use the accounting practice of extrapolation to calculate overpayments or underpayments;
(ii)
except as provided in paragraph (2) of this subsection:
(1)
share information from an audit with another pharmacy benefits manager; or
(2)
use information from an audit conducted by another pharmacy benefits manager;
(iii)
recoup any funds from or charge any fees to a pharmacy or pharmacist for a prescription with regard to an incorrect days of supply calculation if the package size of the medication is unbreakable and the pharmacy benefits manager cannot accept the correct mathematically calculable days’ supply during prescription adjudication;
(iv)
have or request access to a pharmacy’s or pharmacist’s bank, credit card, or depository statements or data as it relates to cost–sharing; or
(v)
audit claims that were reversed or for which there was no remuneration by the purchaser or cost to the pharmacy customer except if necessary to evaluate compliance to a contract.
(2)
Paragraph (1)(ii) of this subsection does not apply to the sharing of information:
(i)
required by federal or State law;
(ii)
in connection with an acquisition or merger involving the pharmacy benefits manager; or
(iii)
at the payor’s request or under the terms of the agreement between the pharmacy benefits manager and the payor.
(j)
A pharmacy benefits manager or purchaser may not audit more than 125 prescriptions during a desk or site audit.
(k)
The recoupment of a claims payment from a pharmacy or pharmacist by a pharmacy benefits manager shall be based on an actual overpayment or denial of an audited claim unless the projected overpayment or denial is part of a settlement agreed to by the pharmacy or pharmacist.
(l)
(1)
In this subsection, “overpayment” means a payment by the pharmacy benefits manager to a pharmacy or pharmacist that is greater than the rate or terms specified in the contract between the pharmacy or pharmacist and the pharmacy benefits manager at the time that the payment is made.
(2)
A clerical error, record–keeping error, typographical error, or scrivener’s error in a required document or record may not constitute fraud or grounds for recoupment of a claims payment from a pharmacy or pharmacist by a pharmacy benefits manager if the prescription was otherwise legally dispensed and the claim was otherwise materially correct.
(3)
Notwithstanding paragraph (2) of this subsection, claims remain subject to recoupment of overpayment or payment of any discovered underpayment by the pharmacy benefits manager.
(m)
(1)
A pharmacy benefits manager shall establish an internal appeals process under which a pharmacy or pharmacist may appeal any disputed claim in a preliminary audit report.
(2)
Under the internal appeals process, a pharmacy benefits manager shall allow a pharmacy or pharmacist to request an internal appeal within 30 working days after receipt of the preliminary audit report, with reasonable extensions allowed.
(3)
The pharmacy benefits manager shall include in its preliminary audit report a written explanation of the internal appeals process, including the name, address, and telephone number of the person to whom an internal appeal should be addressed.
(4)
The decision of the pharmacy benefits manager on an appeal of a disputed claim in a preliminary audit report by a pharmacy or pharmacist shall be reflected in the final audit report.
(5)
The pharmacy benefits manager shall deliver the final audit report to the pharmacy or pharmacist within 30 calendar days after conclusion of the internal appeals process.
(n)
(1)
A pharmacy benefits manager may not recoup by setoff any money for an overpayment or denial of a claim until:
(i)
the pharmacy or pharmacist has an opportunity to review the pharmacy benefits manager’s findings; and
(ii)
if the pharmacy or pharmacist concurs with the pharmacy benefits manager’s findings of overpayment or denial, 30 working days have elapsed after the date the final audit report has been delivered to the pharmacy or pharmacist.
(2)
If the pharmacy or pharmacist does not concur with the pharmacy benefits manager’s findings of overpayment or denial, the pharmacy benefits manager may not recoup by setoff any money pending the outcome of an appeal under subsection (m) of this section.
(3)
A pharmacy benefits manager shall remit any money due to a pharmacy or pharmacist as a result of an underpayment of a claim within 30 working days after the final audit report has been delivered to the pharmacy or pharmacist.
(4)
Notwithstanding the provisions of paragraph (1) of this subsection, a pharmacy benefits manager may withhold future payments before the date the final audit report has been delivered to the pharmacy or pharmacist if the identified discrepancy for all disputed claims in a preliminary audit report for an individual audit exceeds $25,000.
(o)
(1)
A pharmacy benefits manager shall provide a pharmacy or pharmacist being audited with a phone number and, if available, access to a secure portal that the pharmacy or pharmacist may use to ask questions regarding the audit.
(2)
An individual who is familiar with the audit shall respond to all inquiries made through a phone number or secure portal provided under paragraph (1) of this subsection within 3 business days after the inquiry was made.
(p)
(1)
The pharmacy benefits manager shall give the pharmacy or pharmacist the option to provide requested audit documentation by postal mail, e–mail, or facsimile.
(2)
If a document is requested regarding an audit, the pharmacy benefits manager shall provide a secure facsimile number and a mechanism for receiving secure e–mails.
(3)
On or before October 1, 2025, a pharmacy benefits manager shall provide a mechanism for secure electronic communication for pharmacies and pharmacists to communicate with and submit documents to the auditing entity.
(q)
(1)
The Commissioner may adopt regulations regarding:
(i)
the documentation that may be requested during an audit; and
(ii)
the process a pharmacy benefits manager may use to conduct an audit.
(2)
On request of the Commissioner or the Commissioner’s designee, a pharmacy benefits manager shall provide a copy of its audit procedures or internal appeals process.
Md. Code Ann., Ins. § 15-1630 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1630LinkCopy Citation
(a)
This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)
A pharmacy benefits manager shall establish a reasonable internal review process for a pharmacy to request the review of a failure to pay the contractual reimbursement amount of a submitted claim.
(c)
A pharmacy may request a pharmacy benefits manager to review a failure to pay the contractual reimbursement amount of a claim within 180 calendar days after the date the submitted claim was paid by the pharmacy benefits manager.
(d)
The pharmacy benefits manager shall give written notice of its review decision within 90 calendar days after receipt of a request for review from a pharmacy under this section.
(e)
If the pharmacy benefits manager determines through the internal review process established under subsection (b) of this section that the pharmacy benefits manager underpaid a pharmacy, the pharmacy benefits manager shall pay any money due to the pharmacy within 30 working days after completion of the internal review process.
(f)
This section may not be construed to limit the ability of a pharmacy and a pharmacy benefits manager to contractually agree that a pharmacy may have more than 180 calendar days to request an internal review of a failure of the pharmacy benefits manager to pay the contractual amount of a submitted claim.
Md. Code Ann., Ins. § 15-1631 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1631LinkCopy Citation
Except for an overpayment as defined in § 15–1629(h) of this subtitle, if a claim has been approved by a pharmacy benefits manager through adjudication, the pharmacy benefits manager may not retroactively deny or modify reimbursement to a pharmacy or pharmacist for the approved claim unless:
(1)
the claim was fraudulent;
(2)
the pharmacy or pharmacist had been reimbursed for the claim previously; or
(3)
the services reimbursed were not rendered by the pharmacy or pharmacist.
Md. Code Ann., Ins. § 15-1633 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1633LinkCopy Citation
The provisions of §§ 15–1633.1 through 15–1639 of this subtitle apply only to a pharmacy benefits manager performing pharmacy benefits management services on behalf of a carrier.
Md. Code Ann., Ins. § 15-1633.1 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1633.1LinkCopy Citation
A pharmacy benefits manager or its agent may not request a therapeutic interchange unless:
(1)
the proposed therapeutic interchange is for medical reasons that benefit the beneficiary; or
(2)
the proposed therapeutic interchange will result in financial savings and benefits to the purchaser or the beneficiary.
Md. Code Ann., Ins. § 15-1634 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1634LinkCopy Citation
(a)
Before making a therapeutic interchange, a pharmacy benefits manager or its agent shall obtain authorization from a prescriber or an individual authorized by the prescriber.
(b)
In any therapeutic interchange solicitation, the following shall be disclosed to the prescriber:
(1)
that a therapeutic interchange is being solicited;
(2)
the circumstances under which the originally prescribed drug will be covered by the purchaser;
(3)
the difference in copayments or coinsurance to be paid by the beneficiary to obtain the proposed drug;
(4)
the circumstances and extent to which health care costs related to the therapeutic interchange will be compensated; and
(5)
any clinically significant differences, as determined by a pharmacy and therapeutics committee of the pharmacy benefits manager, with respect to efficacy, side effects, and potential impact on health and safety.
(c)
When soliciting a therapeutic interchange from a prescriber, a pharmacy benefits manager or its agent may not make a claim that the therapeutic interchange will save the purchaser money unless the claim can be substantiated.
(d)
If the pharmacy benefits manager or its agent receives payment for making a therapeutic interchange from a pharmaceutical manufacturer or other person, including the pharmacy benefits manager, that is not reflected in cost savings to the purchaser, the existence of the payment shall be communicated to the prescriber at the time of the therapeutic interchange solicitation.
Md. Code Ann., Ins. § 15-1635 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1635LinkCopy Citation
If a therapeutic interchange occurs, the pharmacy benefits manager or its agent shall:
(1)
disclose to the beneficiary, orally or in writing:
(i)
that the pharmacy benefits manager or its agent requested a therapeutic interchange by contacting the beneficiary’s prescriber;
(ii)
the prescriber approved the therapeutic interchange;
(iii)
the names of the originally prescribed drug and the drug dispensed pursuant to the therapeutic interchange;
(iv)
the difference in copayments or coinsurance to be paid by the beneficiary to obtain the drug dispensed pursuant to the therapeutic interchange;
(v)
the circumstances under which the originally prescribed drug will be covered;
(vi)
the circumstances under and the extent to which health care costs related to the therapeutic interchange will be compensated; and
(vii)
that the beneficiary may decline the therapeutic interchange if the originally prescribed drug remains on the beneficiary’s formulary, and the beneficiary is willing to pay any difference in the copayment or coinsurance; and
(2)
include with the prescription drug dispensed:
(i)
a patient package insert about potential side effects; and
(ii)
a toll–free telephone number to communicate with the pharmacy benefits manager.
Md. Code Ann., Ins. § 15-1636 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1636LinkCopy Citation
(a)
A pharmacy benefits manager or its agent shall cancel and reverse a therapeutic interchange on written or verbal instructions from a prescriber, the beneficiary, or the beneficiary’s representative.
(b)
If a therapeutic interchange is reversed, the pharmacy benefits manager or its agent shall:
(1)
obtain a prescription for and dispense the originally prescribed prescription drug; and
(2)
charge the beneficiary no more than one copayment.
(c)
If the therapeutic interchange occurred through a mail order pharmacy and a beneficiary will exhaust an existing supply of the originally prescribed prescription drug before a replacement shipment will arrive to the beneficiary, the pharmacy benefits manager or its agent shall arrange for dispensing of an appropriate quantity of replacement prescription drugs at a local community pharmacy at no additional cost to the beneficiary.
(d)
A pharmacy benefits manager or its agent may not be required to cancel and reverse a therapeutic interchange if a beneficiary is unwilling to pay a higher copayment or coinsurance associated with the originally prescribed prescription drug.
Md. Code Ann., Ins. § 15-1637 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1637LinkCopy Citation
(a)
A pharmacy benefits manager shall maintain a toll–free telephone number Monday through Saturday for prescribers, pharmacies, pharmacists, and beneficiaries to request information regarding a therapeutic interchange.
(b)
The toll–free telephone number shall be accessible from 8 a.m. until at least 8 p.m. Eastern Standard Time.
Md. Code Ann., Ins. § 15-1638 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1638LinkCopy Citation
All disclosures made under this part shall comply with the privacy standards set forth in State and federal law.
Md. Code Ann., Ins. § 15-1639 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1639LinkCopy Citation
A pharmacy benefits manager shall establish appropriate policies and procedures to implement the requirements of this part.
Md. Code Ann., Ins. § 15-1642 (2026)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers
§ 15–1642LinkCopy Citation
(a)
It is a violation of this subtitle for a pharmacy benefits manager to:
(1)
misrepresent pertinent facts or policy provisions that relate to a claim or the compensation program at issue in a complaint or an appeal of a decision regarding a complaint;
(2)
refuse to pay a claim for an arbitrary or capricious reason based on all available information;
(3)
fail to settle a claim or dispute promptly whenever liability is reasonably clear under one part of a policy or contract, in order to influence settlements under other parts of the policy or contract; or
(4)
fail to act in good faith.
(b)
It is a violation of this subtitle for a pharmacy benefits manager, when committed at a frequency to indicate a general business practice, to:
(1)
misrepresent pertinent facts or policy provisions that relate to a claim, the compensation program, or the coverage at issue in a complaint or an appeal of a decision regarding a complaint;
(2)
fail to make a prompt, fair, and equitable good–faith attempt to settle claims for which liability has become reasonably clear;
(3)
fail to settle a claim promptly whenever liability is reasonably clear under one part of a policy or contract, in order to influence settlements under other parts of the policy or contract; or
(4)
refuse to pay a claim for an arbitrary or capricious reason based on all available information.
(c)
If the Commissioner determines that a pharmacy benefits manager has violated any provision of this subtitle or any regulation adopted under this subtitle, the Commissioner may issue an order that requires the pharmacy benefits manager to:
(1)
cease and desist from the identified violation and further similar violations;
(2)
take specific affirmative action to correct the violation;
(3)
make restitution of money, property, or other assets to a person that has suffered financial injury because of the violation; or
(4)
pay a fine in an amount determined by the Commissioner.
(d)
(1)
An order of the Commissioner issued under this section may be served on a pharmacy benefits manager that is registered under Part II of this subtitle in the manner provided in § 2–204 of this article.
(2)
An order of the Commissioner issued under this section may be served on a pharmacy benefits manager that is not registered under Part II of this subtitle in the manner provided in § 4–206 or § 4–207 of this article for service on an unauthorized insurer that does an act of insurance business in the State.
(3)
A request for a hearing on any order issued under this section does not stay that portion of the order that requires the pharmacy benefits manager to cease and desist from conduct identified in the order.
(4)
The Commissioner may file a petition in the circuit court of any county to enforce an order issued under this section, whether or not a hearing has been requested or, if requested, whether or not a hearing has been held.
(5)
If the Commissioner prevails in an action brought under this section, the Commissioner may recover, for the use of the State, reasonable attorney’s fees and the costs of the action.
(e)
In addition to any other enforcement action taken by the Commissioner under this section, the Commissioner may impose a civil penalty not exceeding $10,000 for each violation of this subtitle.
(f)
The Commissioner may adopt regulations:
(1)
to carry out this subtitle; and
(2)
to establish a complaint process to address grievances and appeals brought in accordance with this subtitle.
(g)
This section does not limit any other regulatory authority of the Commissioner under this article.
Subtitle 17. Regulation of Physician Rating Systems
Md. Code Ann., Ins. § 15-1701 (2026)
Title 15. Health Insurance
Subtitle 17. Regulation of Physician Rating Systems
§ 15–1701LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Carrier” has the meaning stated in § 15–1301 of this title.
(c)
“Enrollee” means an individual entitled to health care benefits from a carrier.
(d)
“Physician rating system” means any program that:
(1)
measures, rates, or tiers the performance of physicians under contract with the carrier; and
(2)
discloses the measures, rates, or tiers to enrollees or the public.
(e)
“Ratings examiner” means an independent entity that is approved by the Maryland Health Care Commission to review physician rating systems.
Md. Code Ann., Ins. § 15-1702 (2026)
Title 15. Health Insurance
Subtitle 17. Regulation of Physician Rating Systems
§ 15–1702LinkCopy Citation
(a)
A carrier may not use a physician rating system unless the physician rating system is approved by a ratings examiner.
(b)
A carrier shall contract with and pay for a ratings examiner to review any physician rating system of the carrier.
(c)
A physician rating system of a carrier is deemed to meet the requirements of this section if the physician rating system:
(1)
is approved by a ratings examiner as of January 1, 2010; and
(2)
notwithstanding any revisions to the physician rating system, maintains its approval by the ratings examiner.
Md. Code Ann., Ins. § 15-1703 (2026)
Title 15. Health Insurance
Subtitle 17. Regulation of Physician Rating Systems
§ 15–1703LinkCopy Citation
(a)
A carrier that uses a physician rating system shall:
(1)
establish an appeals process for physicians to use to contest their rating; and
(2)
at least 45 days before making available to enrollees any new or revised quality of performance or cost–efficiency evaluations or any new or revised inclusions or exclusions from a physician rating system, provide each physician included in the physician rating system with:
(i)
a notice of the proposed change;
(ii)
an explanation of the data used to assess the physician and how the physician may access the data;
(iii)
the methodology and measures used to assess the physician;
(iv)
an explanation of the right to contest the rating of the physician through the appeals process of the carrier; and
(v)
instructions on how to file a timely appeal with the carrier.
(b)
If a physician files a timely appeal, as defined by the carrier, regarding the rating of the physician under a physician rating system, the carrier may not disclose the rating of the physician or make a change in the quality of performance or cost–efficiency ratings of the physician until the carrier completes its investigation and renders a decision on the appeal.
(c)
A carrier shall post the following information prominently on the section of the carrier’s Web site that discloses the rating of a physician to enrollees or to the public:
(1)
where an enrollee can find the physician performance ratings of the carrier;
(2)
a disclosure that physician performance ratings are only a guide to choosing a physician because the ratings have a risk of error and should not be the sole basis for selecting a physician;
(3)
an explanation of the physician rating system, including the basis on which physician performance is measured and the basis for determining that a physician is not currently rated due to insufficient data or a pending appeal;
(4)
any limitations of the data that the carrier uses to measure physician performance;
(5)
the factors and criteria used in the carrier’s physician rating system, including quality of performance measures and cost efficiency measures; and
(6)
how a physician may appeal a physician rating.
Md. Code Ann., Ins. § 15-1704 (2026)
Title 15. Health Insurance
Subtitle 17. Regulation of Physician Rating Systems
§ 15–1704LinkCopy Citation
(a)
A carrier shall notify the Commissioner of the results of any final review conducted by a ratings examiner of a physician rating system of the carrier within 45 calendar days after receipt of the results by the carrier.
(b)
If the review conducted by a ratings examiner of a physician rating system of a carrier indicates that the physician rating system does not comply with the requirements of Title 19, Subtitle 1, Part V of the Health – General Article, the Commissioner may order the carrier to:
(1)
correct the deficiency; or
(2)
cease the use of the physician rating system.
(c)
A carrier using a physician rating system shall report annually to the Commissioner:
(1)
the number of appeals filed by physicians under this subtitle; and
(2)
the outcome of the appeals.
Subtitle 19. Clinically Integrated Organizations
Md. Code Ann., Ins. § 15-1901 (2026)
Title 15. Health Insurance
Subtitle 19. Clinically Integrated Organizations
§ 15–1901LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Carrier” means:
(1)
an insurer;
(2)
a nonprofit health service plan; or
(3)
a health maintenance organization.
(c)
“Clinically integrated organization” means:
(1)
a joint venture between a hospital and physicians that:
(i)
has received an advisory opinion from the Federal Trade Commission or its staff; and
(ii)
has been established to:
(1)
evaluate and improve the practice patterns of the health care providers; and
(2)
create a high degree of cooperation, collaboration, and mutual interdependence among the health care providers who participate in the joint venture in order to promote the efficient, medically appropriate delivery of covered medical services; or
(2)
a joint venture between a hospital and physicians that:
(i)
is accountable for total spending and quality; and
(ii)
the Commissioner determines meets the criteria established by the federal Department of Health and Human Services for an accountable care organization.
(d)
“Covered medical services” means the health care services that are included as benefits under a health benefit plan issued by a carrier.
(e)
“Health benefit plan” has the meaning stated in § 15–1301 of this title.
(f)
“Qualifying individual” means an individual covered under a health benefit plan issued by a carrier.
Md. Code Ann., Ins. § 15-1902 (2026)
Title 15. Health Insurance
Subtitle 19. Clinically Integrated Organizations
§ 15–1902LinkCopy Citation
(a)
Notwithstanding any other provision of this article or the Health – General Article, a contract between a carrier and a clinically integrated organization may include a provision to pay:
(1)
for services associated with the coordination of covered medical services to qualifying individuals; and
(2)
a bonus, fee–based incentive, bundled fees, or other incentives to promote the efficient, medically appropriate delivery of covered medical services to qualifying individuals.
(b)
The Commissioner, in consultation with the Maryland Health Care Commission, may adopt regulations specifying the types of payments and incentives permissible under this section.
(c)
(1)
A carrier shall file a copy of a contract between the carrier and a clinically integrated organization with the Commissioner.
(2)
If the contract includes a provision to pay a bonus or other incentive that does not comply with § 15–113 of this title, the Commissioner shall provide a copy of the contract to the executive director of the Maryland Health Care Commission.
(3)
Notwithstanding any other provision of law, a copy of a contract filed with the Commissioner or provided by the Commissioner to the executive director of the Maryland Health Care Commission under this subsection, is:
(i)
confidential and privileged;
(ii)
not subject to:
(1)
Title 4 of the General Provisions Article;
(2)
subpoena; or
(3)
discovery; and
(iii)
not admissible in evidence in any private action.
Md. Code Ann., Ins. § 15-1903 (2026)
Title 15. Health Insurance
Subtitle 19. Clinically Integrated Organizations
§ 15–1903LinkCopy Citation
Notwithstanding any other provision of this article or the Health – General Article, a carrier shall share medical information about a qualifying individual with a clinically integrated organization and its members if:
(1)
the carrier has a written agreement with the clinically integrated organization specifying the type and proposed use of medical information to be shared;
(2)
the medical information is used by the clinically integrated organization to:
(i)
promote the efficient, medically appropriate delivery of covered medical services to qualifying individuals;
(ii)
coordinate care, including efforts to coordinate, plan, develop, monitor, share information related to, and otherwise initiate a treatment plan for a qualifying individual;
(iii)
perform the functions of a medical review committee as described in § 1–401(c) of the Health Occupations Article; or
(iv)
offer or provide covered medical services or seek payment for or evaluate covered medical services provided by the members of the clinically integrated organization; and
(3)
the clinically integrated organization or the carrier implements procedures for disclosing to qualifying individuals how the clinically integrated organization and the carrier share medical information to deliver more coordinated, higher quality care.
Subtitle 20. Pharmacy Services Administrative Organizations
Md. Code Ann., Ins. § 15-2001 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2001LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Independent pharmacy” means a pharmacy operating within the State that is under common ownership with not more than two other pharmacies.
(c)
“Pharmacy benefits manager” has the meaning stated in § 15–1601 of this title.
(d)
“Pharmacy services administrative contract” means a contractual agreement between a pharmacy services administrative organization and an independent pharmacy under which a pharmacy services administrative organization agrees to negotiate with purchasers or pharmacy benefits managers on behalf of one or more independent pharmacies.
(e)
(1)
“Pharmacy services administrative organization” means an entity that provides a contracted pharmacy with contracting administrative services relating to prescription drug benefits.
(2)
“Pharmacy services administrative organization” does not include a nonprofit health maintenance organization that:
(i)
operates as a group model;
(ii)
provides services solely to a member or patient of the nonprofit health maintenance organization; and
(iii)
furnishes services through the internal pharmacy operations of the nonprofit health maintenance organization.
(f)
(1)
“Purchaser” means the State Employee and Retiree Health and Welfare Benefits Program, an insurer, a nonprofit health services plan, or a health maintenance organization that provides prescription drug coverage or benefits in the State.
(2)
“Purchaser” does not include a person that provides prescription drug coverage or benefits through plans subject to the Employee Retirement Income Security Act of 1974 and does not provide prescription drug coverage or benefits through insurance, unless the person is a multiple employer welfare arrangement as defined in § 514(b)(6)(A)(ii) of the Employee Retirement Income Security Act of 1974.
Md. Code Ann., Ins. § 15-2002 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2002LinkCopy Citation
(a)
On or after July 1, 2021, a pharmacy services administrative organization shall register with the Commissioner as a pharmacy services administrative organization before providing services as a pharmacy services administrative organization in the State to independent pharmacies.
(b)
An applicant for registration shall:
(1)
file with the Commissioner an application on the form that the Commissioner provides; and
(2)
pay to the Commissioner a registration fee set by the Commissioner.
Md. Code Ann., Ins. § 15-2003 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2003LinkCopy Citation
(a)
A pharmacy services administrative organization registration expires on the second September 30 after its effective date unless it is renewed as provided under this section.
(b)
A pharmacy services administrative organization may renew its registration for an additional 2–year term if the pharmacy services administrative organization:
(1)
otherwise is entitled to be registered;
(2)
files with the Commissioner a renewal application on the form that the Commissioner requires; and
(3)
pays to the Commissioner a renewal fee set by the Commissioner.
Md. Code Ann., Ins. § 15-2004 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2004LinkCopy Citation
A pharmacy services administrative organization that has not registered with the Commissioner may not enter into an agreement or a contract with an independent pharmacy.
Md. Code Ann., Ins. § 15-2005 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2005LinkCopy Citation
Subject to the applicable hearing provisions of Title 2 of this article, the Commissioner may deny a registration to a pharmacy services administrative organization or refuse to renew, suspend, or revoke the registration of a pharmacy services administrative organization if the pharmacy services administrative organization, or an officer, a director, or an employee of the pharmacy services administrative organization:
(1)
makes a material misstatement or misrepresentation in an application for registration;
(2)
fraudulently or deceptively obtains or attempts to obtain a registration;
(3)
in connection with the administration of pharmacy services administrative organization services, commits fraud or engages in illegal activities; or
(4)
violates this subtitle or a regulation adopted under this subtitle.
Md. Code Ann., Ins. § 15-2006 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2006LinkCopy Citation
A pharmacy services administrative organization shall maintain adequate books and records regarding each independent pharmacy for which the pharmacy services administrative organization provides services as a pharmacy services administrative organization:
(1)
in accordance with prudent standards of record keeping;
(2)
for the duration of the agreement between the pharmacy services administrative organization and the independent pharmacy; and
(3)
for 3 years after the pharmacy services administrative organization ceases to provide services as a pharmacy services administrative organization for the independent pharmacy.
Md. Code Ann., Ins. § 15-2007 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2007LinkCopy Citation
(a)
Whenever the Commissioner considers it advisable, the Commissioner may examine the affairs, transactions, accounts, and records of a registered pharmacy services administrative organization.
(b)
The examination shall be conducted in accordance with § 2–207 of this article.
(c)
The expense of the examination shall be paid in accordance with § 2–208 of this article.
(d)
The reports of the examination and investigation shall be issued in accordance with § 2–209 of this article.
Md. Code Ann., Ins. § 15-2008 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2008LinkCopy Citation
The Commissioner may adopt regulations to implement this subtitle.
Md. Code Ann., Ins. § 15-2009 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2009LinkCopy Citation
This subtitle may not be construed to diminish the authority of the Office of the Attorney General or the Commissioner to obtain information relating to a pharmacy services administrative organization and use the information in any proceeding.
Md. Code Ann., Ins. § 15-2010 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2010LinkCopy Citation
(a)
A pharmacy services administrative contract or an amendment to a pharmacy services administrative contract may not become effective unless:
(1)
at least 60 days before the contract or amendment is to become effective, the pharmacy services administrative organization files the contract or, if required, amendment with the Commissioner in the form required by the Commissioner; and
(2)
the Commissioner does not disapprove the filing within 60 days after the contract or amendment is filed.
(b)
Notice from the Commissioner that a filed contract or amendment to a contract may be used in the State constitutes a waiver of any unexpired part of the filing period.
(c)
The Commissioner shall adopt regulations to:
(1)
establish the circumstances under which the Commissioner may disapprove a contract; and
(2)
specify the types of amendments to a contract required to be filed under subsection (a) of this section.
Md. Code Ann., Ins. § 15-2011 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2011LinkCopy Citation
(a)
A pharmacy services administrative contract shall include a provision that requires the pharmacy services administrative organization to provide to the independent pharmacy an electronic or paper copy of any contracts, amendments, payment schedules, or reimbursement rates within 5 working days after the execution of a contract, or an amendment to a contract, signed on behalf of the independent pharmacy by the pharmacy services administrative organization.
(b)
A pharmacy services administrative contract may prohibit an independent pharmacy from disclosing the documents provided to the independent pharmacy under subsection (a) of this section to any competitor of the pharmacy services administrative organization.
Md. Code Ann., Ins. § 15-2012 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2012LinkCopy Citation
(a)
Each pharmacy services administrative organization shall disclose to the Commissioner the extent of any ownership or control of the pharmacy services administrative organization by any parent company, subsidiary, or other organization that:
(1)
provides pharmacy services;
(2)
provides prescription drug or device services; or
(3)
manufactures, sells, or distributes prescription drugs, biologics, or medical devices.
(b)
Each pharmacy services administrative organization shall notify the Commissioner in writing within 5 working days after any material change in its ownership or control relating to any company, subsidiary, or other organization described under subsection (a) of this section.
Md. Code Ann., Ins. § 15-2013 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2013LinkCopy Citation
(a)
Before entering into a pharmacy services administrative contract, a pharmacy services administrative organization shall provide to an independent pharmacy a written disclosure of ownership or control.
(b)
The disclosure required under subsection (a) of this section shall include the extent of any ownership or control by any parent company, subsidiary, or other organization that:
(1)
provides pharmacy services;
(2)
provides prescription drug or device services; or
(3)
manufactures, sells, or distributes prescription drugs, biologics, or medical devices.
(c)
A pharmacy services administrative contract shall require a pharmacy services administrative organization to notify an independent pharmacy in writing within 5 working days after any material change in its ownership or control related to any company, subsidiary, or other organization described under subsection (b) of this section.
Md. Code Ann., Ins. § 15-2014 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2014LinkCopy Citation
(a)
Before entering into a contract with a purchaser or pharmacy benefits manager, a pharmacy services administrative organization shall provide to the purchaser or pharmacy benefits manager a written disclosure of ownership or control.
(b)
The disclosure required under subsection (a) of this section shall include the extent of any ownership or control by any parent company, subsidiary, or other organization that:
(1)
provides pharmacy services;
(2)
provides prescription drug or device services; or
(3)
manufactures, sells, or distributes prescription drugs, biologics, or medical devices.
(c)
A contract with a purchaser or pharmacy benefits manager shall provide that a pharmacy services administrative organization shall notify the purchaser or pharmacy benefits manager in writing within 5 working days after any material change in its ownership or control related to any company, subsidiary, or other organization described in subsection (b) of this section.
Md. Code Ann., Ins. § 15-2015 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2015LinkCopy Citation
A pharmacy services administrative contract shall:
(1)
require all remittances for claims submitted by a pharmacy benefits manager or purchaser on behalf of an independent pharmacy to be passed by the pharmacy services administrative organization to the independent pharmacy within a reasonable amount of time; and
(2)
specify the reasonable amount of time in which the pharmacy services administrative organization is required to pass the remittances received from the pharmacy benefits manager or purchaser to the independent pharmacy.
Md. Code Ann., Ins. § 15-2016 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2016LinkCopy Citation
(a)
A pharmacy services administrative organization that owns or is owned by, in whole or in part, an entity that manufactures, sells, or distributes prescription drugs, biologics, or medical devices may not require, as a condition of entering into a pharmacy services administrative contract, that an independent pharmacy purchase any drugs, biologics, or medical devices from the entity.
(b)
A pharmacy services administrative organization that owns or is owned by, in whole or in part, any entity that manufactures, sells, or distributes prescription drugs, biologics, or medical devices shall disclose to the Commissioner any agreement with an independent pharmacy under which the independent pharmacy purchases prescription drugs, biologics, or medical devices from the entity.
Md. Code Ann., Ins. § 15-2017 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2017LinkCopy Citation
(a)
All disclosures made under this subtitle shall comply with the privacy standards established in federal and State law.
(b)
A contract or amendment to a contract submitted to the Commissioner as required by this subtitle:
(1)
is considered to be confidential and proprietary information; and
(2)
is not subject to disclosure under the Public Information Act.
Md. Code Ann., Ins. § 15-2018 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2018LinkCopy Citation
A pharmacy services administrative organization shall establish appropriate policies and procedures to implement the requirements of this subtitle.
Md. Code Ann., Ins. § 15-2019 (2026)
Title 15. Health Insurance
Subtitle 20. Pharmacy Services Administrative Organizations
§ 15–2019LinkCopy Citation
(a)
A pharmacy services administrative organization may not:
(1)
misrepresent pertinent facts or policy provisions that relate to an issue in a dispute or an appeal of a decision regarding a dispute;
(2)
refuse to pay or reimburse an independent pharmacy for an arbitrary or capricious reason based on all available information;
(3)
fail to settle a dispute promptly whenever liability is reasonably clear under one part of a policy or contract, in order to influence settlements under other parts of the policy or contract;
(4)
fail to act in good faith; or
(5)
engage in any activity that is a prohibited activity for a pharmacy benefits manager under Subtitle 16 of this title or a regulation adopted under Subtitle 16 of this title.
(b)
If the Commissioner determines that a pharmacy services administrative organization has violated any provision of this subtitle or any regulation adopted under this subtitle, the Commissioner may issue an order that requires a pharmacy services administrative organization to:
(1)
cease and desist from the identified violation and further similar violations;
(2)
take specific affirmative action to correct the violation;
(3)
make restitution of money, property, and other assets to a person that has suffered financial injury because of the violation; or
(4)
pay a fine in the amount determined by the Commissioner.
(c)
(1)
An order of the Commissioner issued under this section may be served on a pharmacy services administrative organization that is registered under § 15–2002 of this subtitle in the manner provided in § 2–204 of this article.
(2)
An order of the Commissioner issued under this section may be served on a pharmacy services administrative organization that is not registered under § 15–2002 of this subtitle in the manner provided in § 4–206 or § 4–207 of this article for service on an unauthorized insurer that does an act of insurance business in the State.
(3)
A request for a hearing on any order issued under this section does not stay that portion of the order that requires the pharmacy services administrative organization to cease and desist from the conduct identified in the order.
(4)
The Commissioner may file a petition in the circuit court of any county to enforce an order issued under this section, whether or not a hearing has been requested or, if requested, whether or not a hearing has been held.
(5)
If the Commissioner prevails in an action brought under this section, the Commissioner may recover, for the use of the State, reasonable attorney’s fees and the costs of the action.
(d)
In addition to any other enforcement action taken by the Commissioner under this section, the Commissioner may impose a civil penalty not exceeding $10,000 for each violation of this subtitle.
(e)
The Commissioner may adopt regulations:
(1)
to carry out this section; and
(2)
to establish a complaint process to address grievances and appeals brought in accordance with this section.
(f)
This section does not limit any other regulatory authority of the Commissioner under this article.
Subtitle 21. Capitated Payments
Md. Code Ann., Ins. § 15-2101 (2026)
Title 15. Health Insurance
Subtitle 21. Capitated Payments
§ 15–2101LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
“Administrator” means a carrier administering a self–funded group health plan.
(c)
“Carrier” has the meaning stated in § 15–113 of this title.
(d)
“Health benefit plan” has the meaning stated in § 2–112.2 of this article.
(e)
“Health care practitioner” has the meaning stated in § 15–113 of this title.
(f)
“Member” has the meaning stated in § 15–10A–01 of this title.
(g)
“Network” has the meaning stated in § 15–112 of this title.
(h)
“Participant” means an employee or an employee’s dependent who participates in a self–funded group health insurance plan.
(i)
“Set of health care practitioners” has the meaning stated in § 15–113 of this title.
Md. Code Ann., Ins. § 15-2102 (2026)
Title 15. Health Insurance
Subtitle 21. Capitated Payments
§ 15–2102LinkCopy Citation
(a)
This section applies to arrangements under a health benefit plan offered by a carrier or a self–funded group health insurance plan in which a capitated payment is:
(1)
calculated as a fixed amount per member or participant assigned or attributed to the health care practitioner or set of health care practitioners;
(2)
to cover the provision of a set of services defined in the health care practitioner’s or set of health care practitioners’ contract and rendered by the health care practitioner or set of health care practitioners; and
(3)
paid periodically regardless of utilization of the services by the members or participants.
(b)
Subject to the requirements of subsection (c) of this section, a health care practitioner or set of health care practitioners is not engaged in insurance business as described in § 4–205 of this article solely because the health care practitioner or set of health care practitioners enters into a contract with a carrier that includes capitated payments for services provided by the health care practitioner or set of health care practitioners.
(c)
A health care practitioner or set of health care practitioners is not engaged in insurance business as described in § 4–205(c) of this article solely because the health care practitioner or set of health care practitioners enters into a contract with an administrator that includes capitated payments for services provided by the health care practitioner or set of health care practitioners to members of a self–funded group health plan if:
(1)
the health care practitioner or set of health care practitioners participates in the administrator’s network and accepts capitated payments;
(2)
the self–funded group health plan retains the obligation to provide access to covered health care benefits to participants; and
(3)
the contract does not include other reimbursement arrangements that are considered acts of an insurance business under § 4–205(c) of this article.
(d)
Notwithstanding subsections (b) and (c) of this section, nothing in this section may be construed to:
(1)
alter any requirement for a carrier or self–funded group health plan to pay a hospital or related institution the rate approved by the Health Services Cost Review Commission for hospital services; or
(2)
supersede the Health Services Cost Review Commission’s jurisdiction or authority over rate review and approval for hospital services.