<section article="gin" article_name="Insurance" number="15-101" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <text>This title does not apply to:</text> <level label="1"> <text>a policy of liability or workers’ compensation and employer’s liability insurance;</text> </level> <level label="2"> <text>a group or blanket policy, except as otherwise provided in this title;</text> </level> <level label="3"> <text>reinsurance; or</text> </level> <level label="4"> <text>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:</text> <level label="i"> <text>provide additional benefits in case of dismemberment, loss of sight, or death by accident or accidental means;</text> </level> <level label="ii"> <text>provide additional benefits for long-term home health care and long-term care in a nursing home or other related institution; or</text> </level> <level label="iii"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-102" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-103" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>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:</text> <level label="1"> <text>written in simplified language; and</text> </level> <level label="2"> <text>approved by the Commissioner as complying with the simplified language standards adopted under subsection (c) of this section.</text> </level> </level> <level label="b"> <text>Subsection (a) of this section applies:</text> <level label="1"> <text>on or after January 2, 1992; or</text> </level> <level label="2"> <text>on or after July 2, 1997, if the policy or certificate was approved by the Commissioner on or before January 1, 1992.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-104" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Specified disease policy” has the meaning stated in § 15-109 of this subtitle.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>other health insurance policies, including commercial individual, group, and blanket policies and policies of nonprofit health service plans;</text> </level> <level label="2"> <text>subscriber contracts that are issued by health maintenance organizations; and</text> </level> <level label="3"> <text>other established programs under which the insured may make a claim.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-105" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Breast implant-related condition” means a condition that the federal Food and Drug Administration recognizes as possibly linked to breast implants.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>An entity subject to this section shall provide information to the Commissioner about the entity’s:</text> <level label="1"> <text>coverage for breast implant removals and breast implant-related conditions; and</text> </level> <level label="2"> <text>preexisting condition provisions in policies for individuals with breast implants.</text> </level> </level> <level label="d"> <level label="1"> <text>On request, the Commissioner shall make available to consumers and licensed physicians the information collected under subsection (c) of this section.</text> </level> <level label="2"> <text>When providing the information, the Commissioner may include a statement that the Commissioner does not guarantee the accuracy of the information.</text> </level> <level label="3"> <text>The Commissioner may set a fee to cover the cost of providing the information under paragraph (1) of this subsection.</text> </level> </level> <level label="e"> <text>A licensed physician may make available to a patient the information obtained from the Commissioner under subsection (d) of this section.</text> </level> <level label="f"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-106" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>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:</text> <level label="i"> <text>shall pay the home medical equipment provider directly if the insured has executed an assignment of benefits; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>shall pay the home medical equipment provider directly if the contract, policy, or certificate of insurance provides for direct payment;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="b"> <text>Authorization may not be terminated until both the provider and beneficiary of the home medical equipment have been notified that authorization is terminated.</text> </level> <level label="c"> <level label="1"> <text>Rented home medical equipment and services may be purchased with the consent of the provider and insurer if:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>there is no material change in the medical condition of the insured, as certified by the attending physician.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-107" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>This section applies to insurers and nonprofit health service plans that issue or deliver individual, group, or blanket health insurance policies in the State.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>exclusion of coverage for classes of drugs as specified by the contract;</text> </level> <level label="2"> <text>changes in prior or preauthorization procedures; or</text> </level> <level label="3"> <text>selection of new prescription claims processors.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-108" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-109" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Loss ratio” means the ratio of losses incurred to premiums earned on policies that are issued, delivered, or renewed in the State.</text> </level> <level label="3"> <text>“Specified disease policy” means a health insurance policy that provides:</text> <level label="i"> <text>benefits only for a disease or diseases specified in the policy or for a treatment unique to a specified disease or diseases; or</text> </level> <level label="ii"> <text>additional benefits for a disease or diseases specified in the policy or for treatment unique to a specified disease or diseases.</text> </level> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-110" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Health care practitioner” has the meaning stated in § 1–301 of the Health Occupations Article.</text> </level> <level label="3"> <text>“Health care service” has the meaning stated in § 1–301 of the Health Occupations Article.</text> </level> <level label="4"> <text>“Prohibited referral” means a referral prohibited by § 1–302 of the Health Occupations Article.</text> </level> </level> <level label="b"> <text>This section applies to insurers and nonprofit health service plans that issue or deliver individual or group health insurance policies in the State.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="g"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-111" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-112" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Accredited hospital” has the meaning stated in § 19–301 of the Health – General Article.</text> </level> <level label="3"> <text>“Ambulatory surgical facility” has the meaning stated in § 19–3B–01 of the Health – General Article.</text> </level> <level label="4"> <text>“Behavioral health care services” has the meaning stated in § 15–127 of this subtitle.</text> </level> <level label="5"> <level label="i"> <text>“Carrier” means:</text> <level label="1"> <text>an insurer;</text> </level> <level label="2"> <text>a nonprofit health service plan;</text> </level> <level label="3"> <text>a health maintenance organization;</text> </level> <level label="4"> <text>a dental plan organization; or</text> </level> <level label="5"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="ii"> <text>“Carrier” includes an entity that arranges a provider panel for a carrier.</text> </level> </level> <level label="6"> <text>“Credentialing intermediary” means a person to whom a carrier has delegated credentialing or recredentialing authority and responsibility.</text> </level> <level label="7"> <text>“Enrollee” means a person entitled to health care benefits from a carrier.</text> </level> <level label="8"> <text>“Group model health maintenance organization” has the meaning stated in § 19–713.6(a) of the Health – General Article.</text> </level> <level label="9"> <text>“Health benefit plan”:</text> <level label="i"> <text>for a group or blanket plan in the large group market, has the meaning stated in § 15–1401 of this title;</text> </level> <level label="ii"> <text>for a group in the small group market, has the meaning stated in § 31–101 of this article; and</text> </level> <level label="iii"> <text>for an individual plan, has the meaning stated in § 15–1301 of this title.</text> </level> </level> <level label="10"> <level label="i"> <text>“Health care facility” means a health care setting or institution providing physical, mental, or substance use disorder health care services.</text> </level> <level label="ii"> <text>“Health care facility” includes:</text> <level label="1"> <text>a hospital;</text> </level> <level label="2"> <text>an ambulatory surgical or treatment center;</text> </level> <level label="3"> <text>a skilled nursing facility;</text> </level> <level label="4"> <text>a residential treatment center;</text> </level> <level label="5"> <text>an urgent care center;</text> </level> <level label="6"> <text>a diagnostic, laboratory, or imaging center;</text> </level> <level label="7"> <text>a rehabilitation facility; and</text> </level> <level label="8"> <text>any other therapeutic health care setting.</text> </level> </level> </level> <level label="11"> <text>“Hospital” has the meaning stated in § 19–301 of the Health – General Article.</text> </level> <level label="12"> <text>“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.</text> </level> <level label="13"> <text>“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.</text> </level> <level label="14"> <text>“Participating provider” means a provider on a carrier’s provider panel.</text> </level> <level label="15"> <text>“Provider” means a health care practitioner or group of health care practitioners licensed, certified, or otherwise authorized by law to provide health care services.</text> </level> <level label="16"> <text>“Provider directory” means a list of a carrier’s participating providers and participating health care facilities.</text> </level> <level label="17"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“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.</text> </level> </level> </level> <level label="b"> <level label="1"> <text>Subject to paragraph (3) of this subsection, a carrier that uses a provider panel shall:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>establish procedures to:</text> <level label="1"> <text>review applications for participation on the carrier’s provider panel in accordance with this section;</text> </level> <level label="2"> <text>notify an enrollee of:</text> </level> <level label="A"> <text>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</text> </level> <level label="B"> <text>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;</text> </level> <level label="3"> <text>notify primary care providers on the carrier’s provider panel of the termination of a specialty referral services provider;</text> </level> <level label="4"> <text>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</text> </level> <level label="5"> <text>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.</text> </level> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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:</text> <level label="i"> <text>ensure that all enrollees, including adults and children, have access to providers and covered services without unreasonable travel or delay;</text> </level> <level label="ii"> <level label="1"> <text>include standards that ensure access to providers, including essential community providers, that serve predominantly low–income and medically underserved individuals; or</text> </level> <level label="2"> <text>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</text> </level> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="4"> <text>The notice required under paragraph (1)(ii)2 of this subsection shall include:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>the telephone number and e–mail address for the office in the Administration that is responsible for receiving and responding to complaints.</text> </level> </level> </level> <level label="c"> <level label="1"> <text>This subsection applies to a carrier that:</text> <level label="i"> <text>is an insurer, a nonprofit health service plan, or a health maintenance organization; and</text> </level> <level label="ii"> <text>uses a provider panel for a health benefit plan offered by the carrier.</text> </level> </level> <level label="2"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>subject to subparagraph (iv) of this paragraph, notify the Commissioner of the impending termination at least 60 days before the anticipated date of termination;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="iii"> <text>The Commissioner may order corrective action if, after review, the access plan is determined not to meet the requirements of this subsection.</text> </level> <level label="iv"> <text>The notice required under subparagraph (ii)1 of this paragraph shall be provided if:</text> <level label="1"> <text>the provider or health care facility provides advance notice to the carrier of its intention to terminate participation in the carrier’s provider panel;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>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.</text> </level> </level> <level label="v"> <text>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:</text> <level label="1"> <text>the provider specialty types affected by the material change; and</text> </level> <level label="2"> <text>unless the network as a whole experienced a 10% reduction, the geographic areas where enrollees were affected by the material change.</text> </level> </level> <level label="vi"> <text>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.</text> </level> </level> <level label="3"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="4"> <text>An access plan filed under this subsection shall include a description of:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>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;</text> </level> <level label="iv"> <text>the carrier’s efforts to address the needs of both adult and child enrollees, including adults and children with:</text> <level label="1"> <text>limited English proficiency or illiteracy;</text> </level> <level label="2"> <text>diverse cultural or ethnic backgrounds;</text> </level> <level label="3"> <text>physical or mental disabilities; and</text> </level> <level label="4"> <text>serious, chronic, or complex health conditions;</text> </level> </level> <level label="v"> <level label="1"> <text>the carrier’s efforts to include providers, including essential community providers, in its network who serve predominantly low–income, medically underserved individuals; or</text> </level> <level label="2"> <text>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;</text> </level> </level> <level label="vi"> <text>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</text> </level> <level label="vii"> <text>the carrier’s methods for assessing the health care needs of enrollees and enrollee satisfaction with health care services provided to them.</text> </level> </level> <level label="5"> <text>Each carrier shall monitor, on an ongoing basis, the clinical capacity of its participating providers to provide covered services to its enrollees.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>In adopting the regulations, the Commissioner may take into consideration:</text> <level label="i"> <text>geographic accessibility of primary care and specialty providers, including mental health and substance use disorder providers;</text> </level> <level label="ii"> <text>waiting times for an appointment with participating primary care and specialty providers, including mental health and substance use disorder providers;</text> </level> <level label="iii"> <text>primary care provider–to–enrollee ratios;</text> </level> <level label="iv"> <text>provider–to–enrollee ratios, by specialty;</text> </level> <level label="v"> <text>geographic variation and population dispersion;</text> </level> <level label="vi"> <text>hours of operation;</text> </level> <level label="vii"> <text>the ability of the network to meet the needs of enrollees, which may include:</text> <level label="1"> <text>low–income individuals;</text> </level> <level label="2"> <text>adults and children with:</text> </level> <level label="A"> <text>serious, chronic, or complex health conditions; or</text> </level> <level label="B"> <text>physical or mental disabilities; and</text> </level> <level label="3"> <text>individuals with limited English proficiency or illiteracy;</text> </level> </level> <level label="viii"> <text>other health care service delivery system options, including telemedicine, telehealth, mobile clinics, and centers of excellence;</text> </level> <level label="ix"> <text>the volume of technological and specialty care services available to serve the needs of enrollees requiring technologically advanced or specialty care services;</text> </level> <level label="x"> <text>any standards adopted by the federal Centers for Medicare and Medicaid Services or used by the Federally Facilitated Marketplace; and</text> </level> <level label="xi"> <text>any standards adopted by another state.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The regulations shall:</text> <level label="i"> <text>ensure that all enrollees, including adults and children, have access to providers and covered services without unreasonable delay and travel;</text> </level> <level label="ii"> <text>ensure access to providers, including essential community providers, that serve predominantly low–income, medically underserved individuals; and</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="3"> <text>In establishing the standards for dental services, the Commissioner may consider the appropriateness of quantitative and nonquantitative criteria.</text> </level> </level> <level label="f"> <text>A carrier that uses a provider panel:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>shall make publicly available its application; and</text> </level> <level label="3"> <text>shall make efforts to increase the opportunity for a broad range of minority providers to participate on the carrier’s provider panel.</text> </level> </level> <level label="g"> <level label="1"> <text>A provider that seeks to participate on a provider panel of a carrier shall submit an application to the carrier.</text> </level> <level label="2"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>a licensed master social worker, as defined in § 19–101 of the Health Occupations Article;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>a registered psychology associate, as defined in § 18–101 of the Health Occupations Article.</text> </level> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="3"> <level label="i"> <text>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:</text> <level label="1"> <text>the carrier’s intent to continue to process the provider’s application to obtain necessary credentialing information; or</text> </level> <level label="2"> <text>the carrier’s rejection of the provider for participation on the carrier’s provider panel.</text> </level> </level> <level label="ii"> <text>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.</text> </level> <level label="iii"> <text>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:</text> <level label="1"> <text>accept or reject the provider for participation on the carrier’s provider panel; and</text> </level> <level label="2"> <text>send written notice of the acceptance or rejection to the provider at the address listed in the application.</text> </level> </level> <level label="iv"> <text>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:</text> <level label="1"> <text>accept or reject the provider for participation on the carrier’s provider panel; and</text> </level> <level label="2"> <text>send written notice of the acceptance or rejection to the provider at the address listed in the application.</text> </level> </level> <level label="v"> <text>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.</text> </level> </level> <level label="4"> <level label="i"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> </level> <level label="ii"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The carrier shall indicate to the provider what information is needed to make the application complete.</text> </level> <level label="3"> <text>The provider may return the completed application to the carrier.</text> </level> <level label="4"> <text>After the carrier receives the completed application, the carrier is subject to the time periods established in paragraph (3) of this subsection.</text> </level> </level> </level> <level label="5"> <text>A carrier may charge a reasonable fee for an application submitted to the carrier under this section.</text> </level> </level> <level label="h"> <text>A carrier may not deny an application for participation or terminate participation on its provider panel on the basis of:</text> <level label="1"> <text>sex, sexual orientation, gender identity, race, age, religion, national origin, or a protected category under the federal Americans with Disabilities Act;</text> </level> <level label="2"> <text>the type or number of appeals that the provider files under Subtitle 10B of this title;</text> </level> <level label="3"> <text>the number of grievances or complaints that the provider files on behalf of a patient under Subtitle 10A of this title; or</text> </level> <level label="4"> <text>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.</text> </level> </level> <level label="i"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>A violation of this subsection does not create a new cause of action.</text> </level> </level> <level label="j"> <level label="1"> <text>Subject to the provisions of this subsection, a carrier may not require a provider participating on its provider panel to be recredentialed based on:</text> <level label="i"> <text>a change in the federal tax identification number of the provider;</text> </level> <level label="ii"> <text>a change in the federal tax identification number of a provider’s employer; or</text> </level> <level label="iii"> <text>a change in the employer of a provider, if the new employer is:</text> <level label="1"> <text>a participating provider on the carrier’s provider panel; or</text> </level> <level label="2"> <text>the employer of providers that participate on the carrier’s provider panel.</text> </level> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>The notice required under paragraph (2) of this subsection shall include:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>the effective date of the change in the federal tax identification number of the provider or the provider’s employer;</text> </level> <level label="iii"> <text>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</text> </level> <level label="iv"> <text>the following information about a new employer of the provider:</text> <level label="1"> <text>the employer’s name;</text> </level> <level label="2"> <text>the name of the employer’s contact person for carrier questions about the provider; and</text> </level> <level label="3"> <text>the address, telephone number, facsimile transmission number, and electronic mail address of the contact person for the employer.</text> </level> </level> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>Within 30 business days after receipt of the notice required under paragraph (2) of this subsection, a carrier:</text> <level label="i"> <text>shall acknowledge receipt of the notice to the provider or the provider’s employer; and</text> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>the provider or the provider’s employer; or</text> </level> <level label="2"> <text>the representative of the provider or the provider’s employer designated in writing to the carrier.</text> </level> </level> </level> <level label="6"> <text>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.</text> </level> </level> <level label="k"> <text>A carrier may not terminate participation on its provider panel or otherwise penalize a provider for:</text> <level label="1"> <text>advocating the interests of a patient through the carrier’s internal review system established under subsection (l) of this section;</text> </level> <level label="2"> <text>filing an appeal under Subtitle 10B of this title; or</text> </level> <level label="3"> <text>filing a grievance or complaint on behalf of a patient under Subtitle 10A of this title.</text> </level> </level> <level label="l"> <text>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.</text> </level> <level label="m"> <level label="1"> <text>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:</text> <level label="i"> <text>who was receiving health care services from the provider before the notice of termination; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>A carrier shall reimburse a provider that furnishes health care services under this subsection in accordance with the provider’s agreement with the carrier.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="n"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The carrier’s provider directory on the Internet shall be available:</text> <level label="i"> <text>through a clear link or tab; and</text> </level> <level label="ii"> <text>in a searchable format.</text> </level> </level> <level label="3"> <text>The provider directory shall include:</text> <level label="i"> <text>for each provider on the carrier’s provider panel:</text> <level label="1"> <text>the name of the provider;</text> </level> <level label="2"> <text>the specialty areas of the provider;</text> </level> <level label="3"> <text>whether the provider currently is accepting new patients;</text> </level> <level label="4"> <text>for each office of the provider where the provider participates on the provider panel:</text> </level> <level label="A"> <text>its location, including its address; and</text> </level> <level label="B"> <text>contact information for the provider;</text> </level> <level label="5"> <text>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</text> </level> <level label="6"> <text>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;</text> </level> </level> <level label="ii"> <text>for each health care facility in the carrier’s network:</text> <level label="1"> <text>the health care facility’s name;</text> </level> <level label="2"> <text>the health care facility’s address;</text> </level> <level label="3"> <text>the types of services provided by the health care facility; and</text> </level> <level label="4"> <text>contact information for the health care facility; and</text> </level> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="o"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="p"> <level label="1"> <text>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.</text> </level> <level label="2"> <level label="i"> <level label="1"> <text>Information provided in printed form under subsection (n) of this section shall be accurate on the date of publication.</text> </level> <level label="2"> <text>A carrier shall update the information provided in printed form at least once a year.</text> </level> </level> <level label="ii"> <level label="1"> <text>Information provided on the Internet under subsection (n) of this section shall be accurate on the date of initial posting and any update.</text> </level> <level label="2"> <text>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.</text> </level> </level> </level> <level label="3"> <text>A carrier shall:</text> <level label="i"> <level label="1"> <text>periodically review at least a reasonable sample size of its provider directory for accuracy; and</text> </level> <level label="2"> <text>retain documentation of the review and make the review available to the Commissioner on request; or</text> </level> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="4"> <text>A carrier shall demonstrate the accuracy of the information provided under paragraph (3) of this subsection on request of the Commissioner.</text> </level> <level label="5"> <text>A carrier shall include in a provider directory that is in printed form a statement notifying a reader that:</text> <level label="i"> <text>the information contained in the provider directory is accurate as of the date of publication; and</text> </level> <level label="ii"> <text>to obtain the most current information, the individual should consult the provider directory on the Internet or contact the carrier directly.</text> </level> </level> <level label="6"> <text>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:</text> <level label="i"> <text>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:</text> <level label="1"> <text>through the multi–carrier common online provider directory information system designated under § 15–112.3 of this subtitle; or</text> </level> <level label="2"> <text>directly with the carrier;</text> </level> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>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;</text> </level> <level label="iv"> <text>the carrier includes in its network directory the last date that a provider updated the provider’s information;</text> </level> <level label="v"> <text>the carrier has implemented any other process or procedure to:</text> <level label="1"> <text>encourage providers to update their network directory information; or</text> </level> <level label="2"> <text>increase the accuracy of its network directory; and</text> </level> </level> <level label="vi"> <text>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.</text> </level> </level> </level> <level label="q"> <text>A policy, certificate, or other evidence of coverage shall:</text> <level label="1"> <text>indicate clearly the office in the Administration that is responsible for receiving and responding to complaints from enrollees about carriers; and</text> </level> <level label="2"> <text>include the telephone number of the office and the procedure for filing a complaint.</text> </level> </level> <level label="r"> <text>The Commissioner:</text> <level label="1"> <text>shall adopt regulations that relate to the procedures that carriers must use to process applications for participation on a provider panel; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="s"> <text>A carrier may not include in a contract with a provider, ambulatory surgical facility, or hospital a term or condition that:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="t"> <level label="1"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>Notification is presumed to have been received by a carrier:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>on the date recorded by the courier, if the notification was delivered by courier.</text> </level> </level> </level> <level label="u"> <level label="1"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>A nonparticipating provider shall notify an enrollee:</text> <level label="i"> <text>that the provider does not participate on the provider panel of the enrollee’s carrier; and</text> </level> <level label="ii"> <text>of the anticipated total charges for the health care services.</text> </level> </level> </level> <level label="v"> <text>The provisions of subsection (g)(3)(iii) of this section do not apply to a carrier that uses a credentialing intermediary that:</text> <level label="1"> <text>is a hospital or academic medical center;</text> </level> <level label="2"> <text>is a participating provider on the carrier’s provider panel; and</text> </level> <level label="3"> <text>acts as a credentialing intermediary for that carrier for health care practitioners that:</text> <level label="i"> <text>participate on the carrier’s provider panel; and</text> </level> <level label="ii"> <text>have privileges at the hospital or academic medical center.</text> </level> </level> </level> <level label="w"> <level label="1"> <text>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:</text> <level label="i"> <text>the provider is employed by or a member of the group practice;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>the provider has a valid license issued by a health occupations board to practice in the State; and</text> </level> <level label="iv"> <text>the provider:</text> <level label="1"> <text>is currently credentialed by an accredited hospital in the State; or</text> </level> <level label="2"> <text>has professional liability insurance.</text> </level> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>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.</text> </level> <level label="6"> <text>A group practice shall disclose in writing to an enrollee at the time services are provided that:</text> <level label="i"> <text>the treating provider is not a participating provider;</text> </level> <level label="ii"> <text>the treating provider has applied to become a participating provider;</text> </level> <level label="iii"> <text>the carrier has not completed its assessment of the qualifications of the treating provider to provide services as a participating provider; and</text> </level> <level label="iv"> <text>any covered services received must be reimbursed by the carrier at the participating provider rate.</text> </level> </level> </level> <level label="x"> <text>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.</text> </level> <level label="y"> <level label="1"> <text>In this subsection, “health system” means:</text> <level label="i"> <text>a hospital and any entity affiliated with the hospital through ownership, governance, membership, or other means; or</text> </level> <level label="ii"> <text>a parent corporation of one or more hospitals and any entity affiliated with the parent corporation through ownership, governance, membership, or other means.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>at least 90 days before the proposed date of the termination of the contract; or</text> </level> <level label="ii"> <text>in the case of nonrenewal, at least 90 days before the end of the contract period.</text> </level> </level> <level label="3"> <level label="i"> <text>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:</text> <level label="1"> <text>at least 90 days after the date of termination; or</text> </level> <level label="2"> <text>in the case of a nonrenewal, at least 90 days after the end of the contract period.</text> </level> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>the date of termination; or</text> </level> <level label="2"> <text>in the case of a nonrenewal, the end date of the contract period.</text> </level> </level> <level label="iii"> <text>This paragraph does not apply if the carrier and health system:</text> <level label="1"> <text>agree, in writing, to the termination or nonrenewal of the contract; and</text> </level> <level label="2"> <text>provide the notices required under paragraph (2) of this subsection.</text> </level> </level> </level> <level label="4"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-112.1" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“Carrier” means:</text> <level label="1"> <text>an insurer;</text> </level> <level label="2"> <text>a nonprofit health service plan;</text> </level> <level label="3"> <text>a health maintenance organization;</text> </level> <level label="4"> <text>a dental plan organization;</text> </level> <level label="5"> <text>a managed care organization; or</text> </level> <level label="6"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="ii"> <text>“Carrier” includes an entity that arranges a provider panel for a carrier.</text> </level> </level> <level label="3"> <text>“Credentialing intermediary” means a person to whom a carrier has delegated credentialing or recredentialing authority and responsibility.</text> </level> <level label="4"> <text>“Health care provider” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.</text> </level> <level label="5"> <text>“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.</text> </level> <level label="6"> <text>“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.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>The requirements of subsection (b) of this section do not apply to a hospital or academic medical center that:</text> <level label="1"> <text>is a participating provider on the carrier’s provider panel; and</text> </level> <level label="2"> <text>acts as a credentialing intermediary for that carrier for health care practitioners that:</text> <level label="i"> <text>participate on the carrier’s provider panel; and</text> </level> <level label="ii"> <text>have privileges at the hospital or academic medical center.</text> </level> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>The Commissioner may adopt regulations to implement the provisions of this section.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the provider credentialing application is available to providers at no charge; and</text> </level> <level label="ii"> <text>use of the provider credentialing application is not conditioned on submitting the provider credentialing application to a carrier through the online credentialing system.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-112.2" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization; or</text> </level> <level label="iv"> <text>a dental plan organization.</text> </level> </level> <level label="4"> <text>“Enrollee” means a person entitled to health care benefits from a carrier.</text> </level> <level label="5"> <text>“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.</text> </level> <level label="6"> <text>“HMO provider panel” means a provider panel for one or more health maintenance organizations.</text> </level> <level label="7"> <text>“Managed care organization” has the meaning stated in § 15–101 of the Health – General Article.</text> </level> <level label="8"> <text>“Non–HMO provider panel” means a provider panel for one or more nonprofit health service plans or insurers.</text> </level> <level label="9"> <text>“Provider” has the meaning stated in § 19–701 of the Health – General Article.</text> </level> <level label="10"> <text>“Provider contract” means a contract:</text> <level label="i"> <text>between a provider and a carrier, an affiliate of a carrier, or an entity that contracts with a provider to serve a carrier; and</text> </level> <level label="ii"> <text>under which the provider agrees to provide health care services to enrollees.</text> </level> </level> <level label="11"> <text>“Provider panel” means the providers that contract either directly or through a subcontracting entity with a carrier to provide health care services to enrollees.</text> </level> </level> <level label="b"> <level label="1"> <text>A provider contract may not contain a provision that requires a provider:</text> <level label="i"> <text>as a condition of participating in a non–HMO provider panel, to participate in an HMO provider panel; or</text> </level> <level label="ii"> <text>as a condition of participating in a fee–for–service dental provider panel, to participate in a capitated dental provider panel.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <text>This subsection does not apply to a provider contract for a dental provider panel.</text> </level> <level label="2"> <text>Each provider contract shall disclose the carriers comprising each provider panel.</text> </level> </level> <level label="d"> <level label="1"> <text>This subsection does not apply to a provider contract for a dental provider panel.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> </level> <level label="e"> <text>If a provider elects to terminate participation on a provider panel, the provider shall:</text> <level label="1"> <text>notify the carrier at least 90 days before the date of termination; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="h"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>A carrier may not include in a vision provider contract a provision that requires a vision provider:</text> <level label="i"> <text>to provide health care services that are not covered services at a fee set by the carrier; or</text> </level> <level label="ii"> <text>to provide discounts on materials that are not covered benefits.</text> </level> </level> <level label="3"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-112.3" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“Carrier” has the meaning stated in § 15–112 of this subtitle.</text> </level> <level label="ii"> <text>“Carrier” does not include a managed care organization, as defined in Title 15, Subtitle 1 of the Health – General Article.</text> </level> </level> <level label="3"> <text>“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.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>the system is available to providers nationally;</text> </level> <level label="2"> <text>the system is available to providers at no charge;</text> </level> <level label="3"> <text>the system allows providers to:</text> <level label="i"> <text>attest online to the accuracy of their information; and</text> </level> <level label="ii"> <level label="1"> <text>correct any inaccurate information; and</text> </level> <level label="2"> <text>attest to the correction; and</text> </level> </level> </level> <level label="4"> <text>the nonprofit alliance has a well–established mechanism for outreach to providers.</text> </level> </level> <level label="c"> <text>A carrier shall accept new and updated provider directory information for a provider submitted:</text> <level label="1"> <level label="i"> <text>through the multi–carrier common online provider directory information system; or</text> </level> <level label="ii"> <text>directly to the carrier; and</text> </level> </level> <level label="2"> <text>from:</text> <level label="i"> <text>the provider;</text> </level> <level label="ii"> <text>a hospital or academic medical center that:</text> <level label="1"> <text>is a participating provider on the carrier’s provider panel; and</text> </level> <level label="2"> <text>acts as a credentialing intermediary for the carrier for providers that:</text> </level> <level label="A"> <text>participate on the carrier’s provider panel; and</text> </level> <level label="B"> <text>have privileges at the hospital or academic medical center; or</text> </level> </level> <level label="iii"> <text>any other person that performs credentialing functions on behalf of a provider.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-113" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization; or</text> </level> <level label="v"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="3"> <text>“Eligible provider” means:</text> <level label="i"> <text>a licensed physician, as defined in § 14–101 of the Health Occupations Article, who voluntarily participates in a two–sided incentive arrangement; or</text> </level> <level label="ii"> <text>a set of health care practitioners that voluntarily participate in a two–sided incentive arrangement.</text> </level> </level> <level label="4"> <text>“Health care practitioner” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.</text> </level> <level label="5"> <text>“Set of health care practitioners” means:</text> <level label="i"> <text>a group practice;</text> </level> <level label="ii"> <text>a clinically integrated organization established in accordance with Subtitle 19 of this title;</text> </level> <level label="iii"> <text>an accountable care organization established in accordance with 42 U.S.C. § 1395jjj and any applicable federal regulations; or</text> </level> <level label="iv"> <text>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.</text> </level> </level> <level label="6"> <text>“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.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <level label="1"> <text>This section does not prohibit a carrier from:</text> <level label="i"> <text>providing bonuses or other incentive–based compensation to a health care practitioner or a set of health care practitioners; or</text> </level> <level label="ii"> <text>entering into a two–sided incentive arrangement with an eligible provider.</text> </level> </level> <level label="2"> <text>A bonus or other incentive–based compensation program or two–sided incentive arrangement authorized under this section:</text> <level label="i"> <text>may not create a disincentive to the provision of medically appropriate or medically necessary health care services; and</text> </level> <level label="ii"> <text>if the carrier is a health maintenance organization, shall comply with the provisions of § 19–705.1 of the Health – General Article.</text> </level> </level> <level label="3"> <text>A bonus or other incentive–based compensation or two–sided incentive arrangement authorized under this section:</text> <level label="i"> <text>if applicable, shall promote health equity, improvement of health care outcomes, and the provision of preventive health care services; or</text> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>the performance measures, including the source of the measures;</text> </level> <level label="2"> <text>the method and the time period for calculating whether the performance measures have been satisfied;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>if applicable, the risk–adjustment method used.</text> </level> </level> </level> <level label="4"> <text>Acceptance of a bonus or other incentive–based compensation or two–sided incentive arrangement under this subsection shall be voluntary.</text> </level> <level label="5"> <text>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.</text> </level> <level label="6"> <text>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.</text> </level> <level label="7"> <text>A carrier may not require as a condition of participation in the carrier’s provider network:</text> <level label="i"> <text>a health care practitioner or set of health care practitioners to participate in the carrier’s bonus or other incentive–based compensation program; or</text> </level> <level label="ii"> <text>an eligible provider to participate in the carrier’s two–sided incentive arrangement program.</text> </level> </level> <level label="8"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>A carrier shall provide a health care practitioner, a set of health care practitioners, or an eligible provider with a copy of:</text> <level label="i"> <text>a schedule of all applicable fees or the 50 most common services billed by a health care practitioner in that specialty, whichever is less;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>the information about the practitioner and the methodology that the carrier uses to determine whether to:</text> <level label="1"> <text>increase or reduce the practitioner’s level of reimbursement;</text> </level> <level label="2"> <text>provide a bonus or other incentive–based compensation to the practitioner; and</text> </level> <level label="3"> <text>recoup compensation from an eligible provider under a two–sided incentive arrangement; and</text> </level> </level> <level label="iv"> <text>a summary of the terms of a two–sided incentive arrangement program.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>in writing before a contract execution;</text> </level> <level label="ii"> <text>in writing or electronically 30 days before a change; and</text> </level> <level label="iii"> <text>in writing or electronically on request of the health care practitioner, set of health care practitioners, or eligible provider.</text> </level> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>The Administration may adopt regulations to carry out the provisions of this subsection.</text> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>Acceptance of a capitated payment shall be voluntary.</text> </level> </level> <level label="f"> <level label="1"> <text>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:</text> <level label="i"> <text>establish a target budget for:</text> <level label="1"> <text>the total cost of care of a population of patients adjusted for risk and population size; or</text> </level> <level label="2"> <text>the cost of an episode of care;</text> </level> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>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;</text> </level> <level label="iv"> <text>provide an opportunity for gains by an eligible provider that is greater than the opportunity for recoupment by the carrier;</text> </level> <level label="v"> <text>following good faith negotiations, provide an opportunity for an audit by an independent third party and an independent third–party dispute resolution process;</text> </level> <level label="vi"> <text>require the carrier and the eligible provider to negotiate in good faith adjustments to the target budget when:</text> <level label="1"> <text>certain circumstances beyond the control of the carrier or the eligible provider arise, including changes in hospital rates; and</text> </level> <level label="2"> <text>material changes occur in health care economics, health care delivery, or regulations that impact the arrangement; and</text> </level> </level> <level label="vii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>any copayment, coinsurance, or deductible that is included in the total cost of care of a patient in the population or episode of care.</text> </level> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>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.</text> </level> <level label="6"> <text>Nothing in this subsection may be construed to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>supersede the Health Services Cost Review Commission’s jurisdiction or authority over rate review and approval for hospital services.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-114" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization; or</text> </level> <level label="v"> <text>any other person that provides dental benefit plans subject to regulation by the State.</text> </level> </level> <level label="3"> <text>“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.</text> </level> <level label="4"> <text>“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.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>If a carrier’s dental provider panel is the sole delivery system offered to employees by an employer, the carrier:</text> <level label="i"> <text>shall offer the employer a dental point–of–service option for the individual employee to accept or reject;</text> </level> <level label="ii"> <text>may not impose a minimum participation level on the dental point–of–service option; and</text> </level> <level label="iii"> <text>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:</text> <level label="1"> <text>the Maryland Health Care Commission for the small group market; and</text> </level> <level label="2"> <text>the Administration for the non–small group market.</text> </level> </level> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-115" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section, “carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization; or</text> </level> <level label="v"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="2"> <text>“Carrier” includes an entity that arranges a provider panel for a carrier.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-116" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization; or</text> </level> <level label="v"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="3"> <text>“Health care provider” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>communications that relate to treatment alternatives;</text> </level> <level label="2"> <text>communications that are necessary or appropriate to maintain the provider-patient relationship while the patient is under the health care provider’s care;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>opinions and the basis of an opinion about public policy issues.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-117" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-118" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Health care service” means a health or medical care procedure or service rendered by a provider that:</text> <level label="i"> <text>provides testing, diagnosis, or treatment of human disease or dysfunction; or</text> </level> <level label="ii"> <text>dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of human disease or dysfunction.</text> </level> </level> <level label="3"> <text>“Provider” means a physician, hospital, or other person that is licensed or otherwise authorized to provide health care services.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide coverage for health care services to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-118.1" future_version_removed="true" future_effective_date="EFFECTIVE UNTIL JULY 1, 2029 PER CHAPTER 692 OF 2025" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions" /> <section article="gin" article_name="Insurance" number="15-119" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>This section applies to insurers and nonprofit health service plans that issue or deliver individual, group, or blanket health insurance policies in the State.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>An entity subject to this section may not impose as a condition of coverage a requirement to:</text> <level label="1"> <text>modify the uniform consultation referral form; or</text> </level> <level label="2"> <text>submit additional consultation referral forms.</text> </level> </level> <level label="d"> <text>The uniform consultation referral form:</text> <level label="1"> <text>shall be properly completed by the health care provider that refers the insured for consultation services; and</text> </level> <level label="2"> <text>may be transmitted electronically.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-120" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-121" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization;</text> </level> <level label="v"> <text>any person or entity acting as a third party administrator; or</text> </level> <level label="vi"> <text>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.</text> </level> </level> <level label="3"> <text>“Contract” means any written agreement between a provider and a carrier for the provider to render health care services to enrollees of the carrier.</text> </level> <level label="4"> <text>“Enrollee” means any person or subscriber entitled to health care benefits from a carrier.</text> </level> <level label="5"> <text>“Health care services” means a health or medical care procedure or service rendered by a provider that:</text> <level label="i"> <text>provides testing, diagnosis, or treatment of a human disease or dysfunction; or</text> </level> <level label="ii"> <text>dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction.</text> </level> </level> <level label="6"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Provider” includes:</text> <level label="1"> <text>a health care facility;</text> </level> <level label="2"> <text>a pharmacy;</text> </level> <level label="3"> <text>a professional services corporation;</text> </level> <level label="4"> <text>a partnership;</text> </level> <level label="5"> <text>a limited liability company;</text> </level> <level label="6"> <text>a professional office; and</text> </level> <level label="7"> <text>any other entity licensed or authorized by law to provide or deliver professional health care services through or on behalf of a provider.</text> </level> </level> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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”):</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>the proportion of every $100 in premium dollars that the carrier uses to pay for plan administration.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-122" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>In this section, “carrier” means:</text> <level label="1"> <text>an insurer;</text> </level> <level label="2"> <text>a nonprofit health service plan;</text> </level> <level label="3"> <text>a health maintenance organization;</text> </level> <level label="4"> <text>a dental plan organization; or</text> </level> <level label="5"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-122.1" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Advance directive” has the meaning stated in § 5–601 of the Health – General Article.</text> </level> <level label="3"> <level label="i"> <text>“Carrier” means:</text> <level label="1"> <text>an insurer;</text> </level> <level label="2"> <text>a nonprofit health service plan;</text> </level> <level label="3"> <text>a health maintenance organization; and</text> </level> <level label="4"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="ii"> <text>“Carrier” does not include a managed care organization.</text> </level> </level> </level> <level label="b"> <text>A carrier shall provide the advance directive information sheet developed under § 5–615 of the Health – General Article:</text> <level label="1"> <text>to all members or enrollees in initial enrollment materials distributed after initial purchase and upon renewal and in the carrier’s member publications;</text> </level> <level label="2"> <text>if the carrier maintains a website, on the carrier’s website; and</text> </level> <level label="3"> <text>at the request of a member.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>This section may not be construed to require a carrier to:</text> <level label="1"> <text>assist a member or enrollee in drafting an electronic advance care planning document;</text> </level> <level label="2"> <text>store electronic advance care planning documents; or</text> </level> <level label="3"> <text>access advance care planning documents.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-123" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization;</text> </level> <level label="v"> <text>any person or entity acting as a third party administrator; or</text> </level> <level label="vi"> <text>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.</text> </level> </level> <level label="3"> <text>“Contract” means any written agreement between a provider and a carrier for the provider to render health care services to enrollees of the carrier.</text> </level> <level label="4"> <text>“Diagnostic services” means any medical or surgical service or procedure that allows a provider to identify or diagnose a human disease or disorder.</text> </level> <level label="5"> <text>“Enrollee” means any person or subscriber entitled to health care benefits from a carrier.</text> </level> <level label="6"> <text>“Health care services” means a health or medical care procedure or service rendered by a provider that:</text> <level label="i"> <text>provides testing, diagnosis, or treatment of a human disease or dysfunction; or</text> </level> <level label="ii"> <text>dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction.</text> </level> </level> <level label="7"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Provider” includes:</text> <level label="1"> <text>a health care facility;</text> </level> <level label="2"> <text>a pharmacy;</text> </level> <level label="3"> <text>a professional services corporation;</text> </level> <level label="4"> <text>a partnership;</text> </level> <level label="5"> <text>a limited liability company;</text> </level> <level label="6"> <text>a professional office; and</text> </level> <level label="7"> <text>any other entity licensed or authorized by law to provide or deliver professional health care services through or on behalf of a provider.</text> </level> </level> </level> <level label="8"> <text>“Therapeutic services” means any medical or surgical service or procedure that a provider can use to treat a human disease or disorder.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>The section does not:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>affect the right of an enrollee to appeal any adverse decision by a carrier through the carrier’s appeal process.</text> </level> </level> <level label="d"> <level label="1"> <text>Each carrier shall disclose to providers and enrollees the carrier’s definition of “experimental medical care”.</text> </level> <level label="2"> <text>The carrier shall disclose the definition in:</text> <level label="i"> <text>contracts offered to providers that may render direct health care services to the enrollees of the carrier; and</text> </level> <level label="ii"> <text>marketing materials and enrollment materials of the carrier that are provided to current enrollees and prospective enrollees, as appropriate.</text> </level> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>The process established or subscribed to or contracted for by a carrier under subsection (e) of this section shall include:</text> <level label="1"> <text>a comprehensive review of medical literature and data evaluation; and</text> </level> <level label="2"> <text>input from physicians and other recognized experts:</text> <level label="i"> <text>who are not employees of the carrier; and</text> </level> <level label="ii"> <text>who:</text> <level label="1"> <text>are currently treating patients for the disease or condition being evaluated;</text> </level> <level label="2"> <text>are board certified in the pertinent specialty or subspecialty area of the disease or condition being evaluated;</text> </level> <level label="3"> <text>are generally recognized by their peers to be authoritative resources in the clinical area being evaluated as evidenced by:</text> </level> <level label="A"> <text>faculty appointments;</text> </level> <level label="B"> <text>authorship of a significant body of peer–reviewed clinical literature in the pertinent specialty or subspecialty area; or</text> </level> <level label="C"> <text>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</text> </level> <level label="4"> <text>have a demonstrated history of substantial experience and practical knowledge in the specialty or subspecialty area in question.</text> </level> </level> </level> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <text>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.</text> </level> <level label="i"> <text>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.</text> </level> <level label="j"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="k"> <text>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.</text> </level> <level label="l"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="m"> <text>The Commissioner may adopt regulations to carry out this section.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-124" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>In this section, “group health insurance” has the meaning stated in § 15–301 of this title.</text> </level> <level label="b"> <text>This section applies to insurers and nonprofit health service plans that issue or deliver group health insurance policies in the State.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-125" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“Carrier” means:</text> <level label="1"> <text>an insurer;</text> </level> <level label="2"> <text>a nonprofit health service plan;</text> </level> <level label="3"> <text>a health maintenance organization;</text> </level> <level label="4"> <text>a dental plan organization; or</text> </level> <level label="5"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="ii"> <text>“Carrier” includes an entity that arranges a provider panel for a carrier.</text> </level> </level> <level label="3"> <text>“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.</text> </level> <level label="4"> <text>“Health care provider” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-126" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>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:</text> <level label="1"> <text>placing the patient’s health in serious jeopardy;</text> </level> <level label="2"> <text>serious impairment to bodily functions; or</text> </level> <level label="3"> <text>serious dysfunction of any bodily organ or part.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-127" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“Behavioral health care administrative expenses” means any expenses that are for administrative functions including:</text> <level label="1"> <text>billing and collection expenses;</text> </level> <level label="2"> <text>accounting and financial reporting expenses;</text> </level> <level label="3"> <text>quality assurance and utilization management program or activity expenses;</text> </level> <level label="4"> <text>promotion and marketing expenses;</text> </level> <level label="5"> <text>taxes, fees, and assessments;</text> </level> <level label="6"> <text>legal expenses;</text> </level> <level label="7"> <text>salary expenses for employees that are not related to the delivery of behavioral health care services to patients;</text> </level> <level label="8"> <text>computer expenses;</text> </level> <level label="9"> <text>provider credentialing;</text> </level> <level label="10"> <text>collection and administrative review of treatment plans;</text> </level> <level label="11"> <text>auditing the financial report submitted to the Commissioner under this section;</text> </level> <level label="12"> <text>debt payment and debt service; and</text> </level> <level label="13"> <text>other general and administrative expenses.</text> </level> </level> <level label="ii"> <text>“Behavioral health care administrative expenses” does not include expenses incurred for behavioral health care services.</text> </level> </level> <level label="3"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Behavioral health care services” includes any quality assurance or utilization management activities or treatment plan reviews that are clinical in nature.</text> </level> <level label="iii"> <text>“Behavioral health care services” does not include administrative functions.</text> </level> </level> <level label="4"> <text>“Carrier” means:</text> <level label="i"> <text>a health insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a preferred provider organization;</text> </level> <level label="v"> <text>a third party administrator; or</text> </level> <level label="vi"> <text>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.</text> </level> </level> <level label="5"> <text>“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.</text> </level> <level label="6"> <text>“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.</text> </level> <level label="7"> <text>“Managed behavioral health care organization” means a company, organization, private review agent, or subsidiary that:</text> <level label="i"> <text>contracts with a carrier to provide, undertake to arrange, or administer behavioral health care services to members; or</text> </level> <level label="ii"> <text>otherwise makes behavioral health care services available to members through contracts with health care providers.</text> </level> </level> <level label="8"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Member” includes a subscriber.</text> </level> </level> <level label="9"> <text>“Provider” means a person licensed, certified, or otherwise authorized under the Health Occupations Article or the Health – General Article to provide health care services.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <level label="1"> <text>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:</text> <level label="i"> <text>the specific behavioral health care services covered and the specific exclusions under the member’s contract;</text> </level> <level label="ii"> <text>the member’s responsibilities for obtaining behavioral health care services;</text> </level> <level label="iii"> <text>the reimbursement methodology that the carrier and managed behavioral health care organization use to reimburse providers for behavioral health care services; and</text> </level> <level label="iv"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>A carrier that owns or contracts with a managed behavioral health care organization shall:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>provide the same information on behavioral health care providers that is required for other providers under § 15–112(n) of this subtitle.</text> </level> </level> <level label="4"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>The report required under subparagraph (i) of this paragraph shall be made publicly available by the carrier.</text> </level> </level> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <text>the carrier’s direct payments for the preceding calendar year;</text> </level> <level label="ii"> <text>the information required to be collected by a carrier under subsection (c)(4) of this section; and</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="2"> <text>The Commissioner shall develop a form to implement the requirements of this subsection.</text> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>a reasonable preparation fee not to exceed $15 for each form requested; and</text> </level> <level label="ii"> <text>the actual cost for any postage and handling required to provide copies of the requested forms.</text> </level> </level> </level> <level label="f"> <text>The Commissioner may adopt regulations to carry out the provisions of this section.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-129" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer; or</text> </level> <level label="ii"> <text>a nonprofit health service plan.</text> </level> </level> <level label="4"> <text>“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.</text> </level> <level label="5"> <text>“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.</text> </level> <level label="6"> <text>“Medical stop–loss insurer” means a carrier that is authorized to sell, issue, and deliver policies of medical stop–loss insurance in the State.</text> </level> <level label="7"> <text>“Small employer” has the meaning stated in § 31–101 of this article.</text> </level> <level label="8"> <text>“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.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <text>a specific attachment point of less than $22,500; or</text> </level> <level label="ii"> <text>an aggregate attachment point of less than 120% of expected claims.</text> </level> </level> <level label="2"> <text>This subsection does not apply to:</text> <level label="i"> <text>a policy or contract of medical stop–loss insurance issued or delivered before June 1, 2015, if the policy or contract maintains:</text> <level label="1"> <text>a specific attachment point of no less than $10,000; and</text> </level> <level label="2"> <text>an aggregate attachment point of no less than 115% of expected claims;</text> </level> </level> <level label="ii"> <text>a renewal of a policy or contract described in item (i) of this paragraph; or</text> </level> <level label="iii"> <text>a policy or contract of medical stop–loss insurance issued or delivered on or after June 1, 2015, if the policy or contract:</text> <level label="1"> <text>is issued or delivered to an employer that on May 31, 2015, held a policy or contract of medical stop–loss insurance with:</text> </level> <level label="A"> <text>a specific attachment point of not less than $10,000; and</text> </level> <level label="B"> <text>an aggregate attachment point of not less than 115% of expected claims; and</text> </level> <level label="2"> <text>maintains:</text> </level> <level label="A"> <text>a specific attachment point of not less than $10,000; and</text> </level> <level label="B"> <text>an aggregate attachment point of not less than 115% of expected claims.</text> </level> </level> </level> </level> <level label="e"> <text>For a stop–loss insurance policy or contract issued to a small employer, a medical stop–loss insurer may not:</text> <level label="1"> <level label="i"> <text>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</text> </level> <level label="ii"> <text>decrease or remove stop–loss coverage for a specific individual within a small employer’s health benefit plan; or</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>physical or behavioral health, including mental illness or substance use disorder;</text> </level> <level label="ii"> <text>claims experience;</text> </level> <level label="iii"> <text>medical history;</text> </level> <level label="iv"> <text>receipt of health care;</text> </level> <level label="v"> <text>genetic information;</text> </level> <level label="vi"> <text>disability;</text> </level> <level label="vii"> <text>evidence of insurability, including conditions arising out of acts of domestic violence against an employee or dependent; or</text> </level> <level label="viii"> <text>any other health status–related factor as determined by the Commissioner.</text> </level> </level> </level> <level label="f"> <text>For a stop–loss insurance policy or contract issued to a small employer, a medical stop–loss insurer shall:</text> <level label="1"> <text>guarantee rates for at least 12 months, without adjustment, unless there is a change in:</text> <level label="i"> <text>the benefits provided under the small employer’s health benefit plan during the policy or contract period;</text> </level> <level label="ii"> <text>the ownership and control of the small employer; or</text> </level> <level label="iii"> <text>the number of covered lives by a significant percentage resulting from an event such as an acquisition or a divestiture;</text> </level> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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:</text> <level label="i"> <text>the total costs of the policy or contract;</text> </level> <level label="ii"> <level label="1"> <text>the dates on which the policy or contract takes effect and terminates; and</text> </level> <level label="2"> <text>provisions for renewing the policy or contract;</text> </level> </level> <level label="iii"> <text>the aggregate attachment point and the specific attachment point for the policy or contract; and</text> </level> <level label="iv"> <text>any limitations on coverage.</text> </level> </level> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <text>Nothing in this section shall be construed as:</text> <level label="1"> <text>imposing any requirement or duty on any person other than a carrier; or</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-130" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>health maintenance organizations that provide coverage for prescription drugs on an outpatient basis under contracts that are issued or delivered in the State;</text> </level> <level label="iii"> <text>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</text> </level> <level label="iv"> <text>to the extent consistent with State and federal law, third party administrators.</text> </level> </level> <level label="2"> <text>This section does not apply to:</text> <level label="i"> <text>short–term travel or accident–only policies;</text> </level> <level label="ii"> <text>short–term nonrenewable policies of not more than 3 months duration; or</text> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <level label="i"> <text>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</text> </level> <level label="ii"> <text>includes, at a minimum, the following data elements:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>the name and identification number of the insured, subscriber, or enrollee;</text> </level> <level label="3"> <text>the telephone number that providers may call for pharmacy benefit assistance; and</text> </level> <level label="4"> <text>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</text> </level> </level> </level> <level label="2"> <text>indicates which State agency regulates, in whole or in part, the policy or contract offered by the entity by:</text> <level label="i"> <text>for an entity subject to the Administration, displaying “MIA” prominently; or</text> </level> <level label="ii"> <text>for an entity subject to the Maryland Department of Health, displaying “MDH” prominently.</text> </level> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>reissue a health insurance benefit card, prescription drug benefit card, or other technology; or</text> </level> <level label="ii"> <text>provide the insured, subscriber, or enrollee with the corrective information necessary to electronically process a prescription claim.</text> </level> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>The Maryland Department of Health shall adopt regulations to enable managed care organizations to comply with:</text> <level label="1"> <text>the requirements of this section; and</text> </level> <level label="2"> <text>any unique requirements of the HealthChoice Program that relate to the electronic processing of claims.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-130.1" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>each health insurer;</text> </level> <level label="2"> <text>each nonprofit health service plan;</text> </level> <level label="3"> <text>each health maintenance organization; and</text> </level> <level label="4"> <text>each managed care organization, as defined in § 15–101 of the Health – General Article.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>for an entity subject to the Administration, displaying “MIA” prominently; or</text> </level> <level label="2"> <text>for an entity subject to the Maryland Department of Health, displaying “MDH” prominently.</text> </level> </level> <level label="c"> <text>This section may not be construed to preclude an entity subject to this section from including:</text> <level label="1"> <text>any other information required to be included under this article; or</text> </level> <level label="2"> <text>any information that is in addition to the information required under this section.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-131" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>An entity subject to this section may not impose a processing fee for the electronic reimbursement or for providing payment data electronically.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-132" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>In this section, “carrier” has the meaning stated in § 19–142 of the Health – General Article.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-133" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-134" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-135" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>“Annual preventive care” includes, if the service is a covered benefit:</text> <level label="i"> <text>an annual child wellness visit;</text> </level> <level label="ii"> <text>a routine gynecological visit;</text> </level> <level label="iii"> <text>a screening test or examination for colorectal cancer, chlamydia, human papillomavirus, prostate cancer, or breast cancer; and</text> </level> <level label="iv"> <text>an annual vision visit that includes a vision examination.</text> </level> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>An entity subject to this section that provides covered benefits for annual preventive care shall provide coverage for the annual preventive care if:</text> <level label="1"> <text>the annual preventive care is provided no more than once at any time during the plan year established in the policy or contract; and</text> </level> <level label="2"> <text>any other requirements for coverage of the annual preventive care are met.</text> </level> </level> <level label="d"> <text>This section may not be construed to require coverage for a service not otherwise required by law.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-135.1" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“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.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>This section may not be construed to require coverage for a service not otherwise required by law.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-136" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization; or</text> </level> <level label="iv"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="3"> <text>“Group model health maintenance organization” has the meaning stated in § 19–713.6(a) of the Health – General Article.</text> </level> </level> <level label="b"> <text>This section applies only to contracts or policies that:</text> <level label="1"> <text>are issued or delivered by a carrier; and</text> </level> <level label="2"> <text>provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis.</text> </level> </level> <level label="c"> <level label="1"> <text>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:</text> <level label="i"> <text>after 6 p.m. and before 8 a.m.; or</text> </level> <level label="ii"> <text>on weekends and national holidays.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-138" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Ambulance service provider” means a provider of ambulance services that:</text> <level label="i"> <text>is owned, operated, or under the jurisdiction of a political subdivision of the State or a volunteer fire company or volunteer rescue squad; or</text> </level> <level label="ii"> <text>has contracted to provide ambulance services for a political subdivision of the State.</text> </level> </level> <level label="4"> <text>“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.</text> </level> <level label="5"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer that provides benefits on an expense–incurred basis;</text> </level> <level label="ii"> <text>a nonprofit health service plan; or</text> </level> <level label="iii"> <text>a health maintenance organization.</text> </level> </level> <level label="6"> <text>“Nonpreferred provider” has the meaning stated in § 14–201 of this article.</text> </level> <level label="7"> <text>“Preferred provider” has the meaning stated in § 14–201 of this article.</text> </level> <level label="8"> <text>“Preferred provider insurance policy” has the meaning stated in § 14–201 of this article.</text> </level> </level> <level label="b"> <text>This section applies to individual or group policies or contracts issued or delivered in the State by a carrier.</text> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>This subsection applies to an ambulance service provider that receives direct reimbursement under subsection (c) of this section.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>An ambulance service provider or a representative of the ambulance service provider may not:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="4"> <text>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:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>any payment or charge for services that are not covered services.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <text>The Commissioner may adopt regulations to implement this section.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-139" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Telehealth” does not include:</text> <level label="i"> <text>except as provided in paragraph (2) of this subsection, an audio–only telephone conversation between a health care provider and a patient;</text> </level> <level label="ii"> <text>an electronic mail message between a health care provider and a patient; or</text> </level> <level label="iii"> <text>a facsimile transmission between a health care provider and a patient.</text> </level> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <level label="1"> <text>An entity subject to this section:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="2"> <text>The health care services appropriately delivered through telehealth shall include counseling and treatment for substance use disorders and mental health conditions.</text> </level> </level> <level label="d"> <level label="1"> <text>Subject to paragraph (2) of this subsection, an entity subject to this section:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>is not required to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>reimburse a health care provider who is not a covered provider under the health insurance policy or contract; and</text> </level> </level> <level label="iii"> <level label="1"> <text>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;</text> </level> <level label="2"> <text>may impose an annual dollar maximum as permitted by federal law; and</text> </level> <level label="3"> <text>may not impose a lifetime dollar maximum.</text> </level> </level> </level> <level label="2"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>The reimbursement required under subparagraph (i) of this paragraph does not include:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>any room and board fees.</text> </level> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-140" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Acute condition” means a medical or dental condition that:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>has a limited duration.</text> </level> </level> <level label="3"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer authorized to sell health insurance;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization; or</text> </level> <level label="v"> <text>any other entity providing a plan of health insurance, health benefits, or health services authorized under this article or the Affordable Care Act.</text> </level> </level> <level label="4"> <text>“Enrollee” means:</text> <level label="i"> <text>a person entitled to health care benefits from a carrier; or</text> </level> <level label="ii"> <text>a Program recipient who is enrolled in a managed care organization.</text> </level> </level> <level label="5"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Health benefit plan” does not include:</text> <level label="1"> <text>coverage only for accident or disability insurance or any combination of accident and disability insurance;</text> </level> <level label="2"> <text>coverage issued as a supplement to liability insurance;</text> </level> <level label="3"> <text>liability insurance, including general liability insurance and automobile liability insurance;</text> </level> <level label="4"> <text>workers’ compensation or similar insurance;</text> </level> <level label="5"> <text>automobile medical payment insurance;</text> </level> <level label="6"> <text>credit–only insurance;</text> </level> <level label="7"> <text>coverage for on–site medical clinics; or</text> </level> <level label="8"> <text>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.</text> </level> </level> <level label="iii"> <text>“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:</text> <level label="1"> <text>limited scope vision benefits;</text> </level> <level label="2"> <text>benefits for long–term care, nursing home care, home health care, community–based care, or any combination of these benefits; or</text> </level> <level label="3"> <text>such other similar limited benefits as are specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act.</text> </level> </level> <level label="iv"> <text>“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:</text> <level label="1"> <text>coverage only for a specified disease or illness; or</text> </level> <level label="2"> <text>hospital indemnity or other fixed indemnity insurance.</text> </level> </level> <level label="v"> <text>“Health benefit plan” does not include the following if offered as a separate policy, certificate, or contract of insurance:</text> <level label="1"> <text>Medicare Supplemental Insurance (as defined under § 1882(g)(1) of the Social Security Act);</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>similar supplemental coverage provided to coverage under a group health plan.</text> </level> </level> </level> <level label="6"> <level label="i"> <text>“Health care provider” means:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>a facility where health care is provided to patients or recipients including:</text> </level> <level label="A"> <text>a hospital, as defined in § 19–301 of the Health – General Article;</text> </level> <level label="B"> <text>a related institution as defined in § 19–301 of the Health – General Article;</text> </level> <level label="C"> <text>a freestanding ambulatory care facility as defined in § 19–3B–01 of the Health – General Article;</text> </level> <level label="D"> <text>a facility that is organized primarily to help in the rehabilitation of persons with disabilities;</text> </level> <level label="E"> <text>a home health agency as defined in § 19–901 of the Health – General Article;</text> </level> <level label="F"> <text>a hospice as defined in § 19–901 of the Health – General Article;</text> </level> <level label="G"> <text>a facility that provides radiological or other diagnostic imagery services;</text> </level> <level label="H"> <text>a medical laboratory as defined in § 17–201 of the Health – General Article;</text> </level> <level label="I"> <text>an alcohol abuse and drug abuse treatment program as defined in § 8–403 of the Health – General Article; and</text> </level> <level label="J"> <text>a Federally Qualified Health Center.</text> </level> </level> <level label="ii"> <text>“Health care provider” includes the agents, employees, officers, and directors of a health care provider described in subparagraph (i) of this paragraph.</text> </level> </level> <level label="7"> <text>“Managed care organization” means:</text> <level label="i"> <text>a certified health maintenance organization that is authorized to receive medical assistance prepaid capitation payments;</text> </level> <level label="ii"> <text>a corporation that:</text> <level label="1"> <text>is a managed care system that is authorized to receive medical assistance prepaid capitation payments;</text> </level> <level label="2"> <text>enrolls only Program recipients or individuals or families served under the Maryland Children’s Health Program; and</text> </level> <level label="3"> <text>is subject to the requirements of § 15–102.4 of the Health – General Article; or</text> </level> </level> <level label="iii"> <text>a prepaid dental plan that receives fees to manage dental services.</text> </level> </level> <level label="8"> <text>“Nonparticipating provider” means a health care provider who is not on the provider panel of a carrier or managed care organization.</text> </level> <level label="9"> <text>“Participating provider” means a health care provider who is on the provider panel of a carrier or managed care organization.</text> </level> <level label="10"> <text>“Prior authorization” means a utilization management technique that:</text> <level label="i"> <text>is used by carriers and managed care organizations;</text> </level> <level label="ii"> <text>requires prior approval for a procedure, treatment, medication, or service before an enrollee is eligible for full payment of the benefit; and</text> </level> <level label="iii"> <text>is used to determine whether the procedure, treatment, medication, or service is medically necessary.</text> </level> </level> <level label="11"> <text>“Program recipient” means an individual who receives benefits under the Maryland Medical Assistance Program.</text> </level> <level label="12"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“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.</text> </level> </level> <level label="13"> <text>“Receiving carrier or managed care organization” means:</text> <level label="i"> <text>the carrier that issues the new health benefit plan when an enrollee transitions from another carrier or a managed care organization; or</text> </level> <level label="ii"> <text>the managed care organization that accepts the enrollee when the enrollee transitions from another managed care organization or a carrier.</text> </level> </level> <level label="14"> <text>“Relinquishing carrier or managed care organization” means:</text> <level label="i"> <text>the carrier that issued the prior health benefit plan when an enrollee transitions to a new carrier or a managed care organization; or</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="15"> <text>“Serious chronic condition” means a medical or dental condition due to a disease, an illness, or any other medical or dental problem that:</text> <level label="i"> <text>is serious in nature;</text> </level> <level label="ii"> <text>persists without full cure or worsens over an extended period of time; and</text> </level> <level label="iii"> <text>is actively managed or supervised by a health care provider to maintain remission or prevent deterioration.</text> </level> </level> <level label="16"> <text>“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.</text> </level> </level> <level label="b"> <level label="1"> <text>The purpose of this section is to advance the State’s progress in:</text> <level label="i"> <text>protecting Marylanders from harmful disruptions in health care services; and</text> </level> <level label="ii"> <text>promoting reasonable continuity of health care for Marylanders when transitioning:</text> <level label="1"> <text>from one carrier to another carrier; and</text> </level> <level label="2"> <text>between a carrier and the Maryland Medical Assistance Program or the Maryland Children’s Health Program.</text> </level> </level> </level> <level label="2"> <text>This section:</text> <level label="i"> <text>with respect to any benefit or service that is provided through the Maryland Medical Assistance fee–for–service program:</text> <level label="1"> <text>shall not apply when the enrollee is transitioning from a carrier to the Maryland Medical Assistance Program; and</text> </level> <level label="2"> <text>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;</text> </level> </level> <level label="ii"> <text>shall apply to contracts issued or renewed on or after January 1, 2015; and</text> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="c"> <level label="1"> <text>With respect to any benefit or service provided through the Maryland Medical Assistance fee–for–service program, this subsection shall apply:</text> <level label="i"> <text>only to enrollees transitioning from the Maryland Medical Assistance Program to a carrier; and</text> </level> <level label="ii"> <text>only to behavioral health and dental benefits, to the extent they are authorized by a third–party administrator.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the procedures, treatments, medications, or services covered by the benefits offered by the receiving carrier or managed care organization; and</text> </level> <level label="ii"> <text>the following time periods:</text> <level label="1"> <text>the lesser of the course of treatment or 90 days; and</text> </level> <level label="2"> <text>the duration of the three trimesters of a pregnancy and the initial postpartum visit.</text> </level> </level> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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:</text> <level label="i"> <text>reassess and make its own determination regarding the need for continued treatment; and</text> </level> <level label="ii"> <text>authorize any continued procedure, treatment, medication, or service determined to be medically necessary.</text> </level> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <level label="i"> <text>The services an enrollee shall be allowed to continue to receive are services for:</text> <level label="1"> <text>the following conditions:</text> </level> <level label="A"> <text>acute conditions;</text> </level> <level label="B"> <text>serious chronic conditions;</text> </level> <level label="C"> <text>pregnancy; and</text> </level> <level label="D"> <text>mental health conditions and substance use disorders; and</text> </level> <level label="2"> <text>any other condition on which the nonparticipating provider and the receiving carrier or managed care organization reach agreement.</text> </level> </level> <level label="ii"> <text>Examples of conditions set forth in subparagraph (i)1A and B of this paragraph may include:</text> <level label="1"> <text>bone fractures;</text> </level> <level label="2"> <text>joint replacements;</text> </level> <level label="3"> <text>heart attacks;</text> </level> <level label="4"> <text>cancer;</text> </level> <level label="5"> <text>HIV/AIDS; and</text> </level> <level label="6"> <text>organ transplants.</text> </level> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="3"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> <level label="iii"> <text>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.</text> </level> <level label="iv"> <text>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.</text> </level> </level> <level label="4"> <text>The rates and methods of payment under paragraph (3)(ii) and (iv) of this subsection shall:</text> <level label="i"> <text>be subject to any State or federal requirements applicable to reimbursement for health care provider services, including:</text> <level label="1"> <text>§ 1302(g) of the Affordable Care Act, which applies to reimbursement rates for Federally Qualified Health Centers; and</text> </level> <level label="2"> <text>Title 19, Subtitle 2 of the Health – General Article, under which the Health Services Cost Review Commission establishes provider rates; and</text> </level> </level> <level label="ii"> <text>ensure that:</text> <level label="1"> <text>an enrollee is not subject to balance billing; and</text> </level> <level label="2"> <text>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.</text> </level> </level> </level> <level label="5"> <text>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:</text> <level label="i"> <text>the nonparticipating provider is not required to continue to provide the services;</text> </level> <level label="ii"> <text>§ 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</text> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>This section does not:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>The rate and method of payment under subparagraph (i) of this paragraph shall comply with:</text> <level label="1"> <text>the prohibition on balance billing under subsection (d)(4)(ii) of this section; and</text> </level> <level label="2"> <text>any copayments, deductibles, and coinsurance requirements in the enrollee’s health benefit plan under the relinquishing carrier.</text> </level> </level> </level> </level> <level label="f"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The requirements of this section are:</text> <level label="i"> <text>in addition to any other legal, professional, or ethical obligations of a carrier or managed care organization to provide continuity of care; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="g"> <text>The Commissioner and the Secretary of Health each may adopt regulations to enforce the requirements of this section.</text> </level> <level label="h"> <level label="1"> <text>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:</text> <level label="i"> <text>assess the implementation and efficacy of the requirements of this section; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-141" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization; or</text> </level> <level label="v"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="3"> <text>“Enrollee” means a person entitled to health care benefits from a carrier.</text> </level> </level> <level label="b"> <text>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).</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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).</text> </level> </section> <section article="gin" article_name="Insurance" number="15-142" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Step therapy drug” means a prescription drug or sequence of prescription drugs required to be used under a step therapy or fail–first protocol.</text> </level> <level label="3"> <text>“Step therapy exception request” means a request to override a step therapy or fail–first protocol.</text> </level> <level label="4"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“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.</text> </level> </level> <level label="5"> <text>“Supporting medical information” means:</text> <level label="i"> <text>a paid claim from an entity subject to this section for an insured or an enrollee;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>other information mutually agreed on by an entity subject to this section and the prescriber of an insured or an enrollee.</text> </level> </level> </level> <level label="b"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>An entity subject to this section may not impose a step therapy or fail–first protocol on an insured or an enrollee if:</text> <level label="1"> <text>the step therapy drug has not been approved by the U.S. Food and Drug Administration for the medical condition being treated; or</text> </level> <level label="2"> <text>a prescriber provides supporting medical information to the entity that a prescription drug covered by the entity:</text> <level label="i"> <text>was ordered by a prescriber for the insured or enrollee within the past 180 days; and</text> </level> <level label="ii"> <text>based on the professional judgment of the prescriber, was effective in treating the insured’s or enrollee’s disease or medical condition.</text> </level> </level> </level> <level label="d"> <text>Subsection (c) of this section may not be construed to require coverage for a prescription drug that is not:</text> <level label="1"> <text>covered by the policy or contract of an entity subject to this section; or</text> </level> <level label="2"> <text>otherwise required by law to be covered.</text> </level> </level> <level label="e"> <text>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:</text> <level label="1"> <level label="i"> <text>the prescription drug is used to treat the insured’s or enrollee’s stage four advanced metastatic cancer; and</text> </level> <level label="ii"> <text>use of the prescription drug is:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>supported by peer–reviewed medical literature;</text> </level> </level> </level> <level label="2"> <text>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</text> </level> <level label="3"> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>use of the prescription drug is:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>supported by peer–reviewed medical literature; and</text> </level> </level> <level label="iii"> <text>the prescription drug is covered under the terms of the policy or contract of the insured or enrollee.</text> </level> </level> </level> <level label="f"> <level label="1"> <text>An entity subject to this section shall establish a process for requesting an exception to a step therapy or fail–first protocol that is:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>easily accessible to the prescriber; and</text> </level> <level label="iii"> <text>posted on the entity’s website.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the step therapy drug is contraindicated or will likely cause an adverse reaction to the insured or enrollee;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>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</text> </level> <level label="iv"> <text>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:</text> <level label="1"> <text>is in the same pharmacologic class or has the same mechanism of action as the step therapy drug; and</text> </level> <level label="2"> <text>was discontinued by the prescriber due to lack of efficacy or effectiveness, diminished effect, or an adverse event.</text> </level> </level> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>An enrollee or insured may appeal a step therapy exception request denial in accordance with Subtitle 10A or Subtitle 10B of this title.</text> </level> <level label="5"> <text>This subsection may not be construed to:</text> <level label="i"> <text>prevent:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>a health care provider from prescribing a prescription drug that is determined to be medically appropriate; or</text> </level> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="6"> <text>An entity subject to this section may use an existing step therapy exception process that satisfies the requirements under this subsection.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-143" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>In this section, “participation agreement” means a contract that:</text> <level label="1"> <text>is executed by a payor or program administrator and other participating entities; and</text> </level> <level label="2"> <text>describes the requirements for participation in a payment model subject to this section.</text> </level> </level> <level label="b"> <text>This section applies only to a payment model described in § 1–302(d)(12) of the Health Occupations Article:</text> <level label="1"> <text>that applies to individuals covered under health insurance; and</text> </level> <level label="2"> <text>under which there is cash compensation.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <text>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:</text> <level label="1"> <text>is insurance business; and</text> </level> <level label="2"> <text>violates this article or a regulation adopted under this article.</text> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <level label="i"> <text>The Commissioner shall hold a hearing before issuing an order under paragraph (1) of this subsection.</text> </level> <level label="ii"> <text>The Commissioner shall give written notice of the hearing to the filer at least 10 days before the hearing.</text> </level> <level label="iii"> <text>The notice shall specify the matters to be considered at the hearing.</text> </level> </level> <level label="3"> <text>If the compensation arrangement between a health care practitioner and a health care entity changes during its term:</text> <level label="i"> <text>the filer shall submit a revised filing to the Commissioner for review of the changes; and</text> </level> <level label="ii"> <text>the Commissioner shall make a new determination, as provided under subsection (d) of this section.</text> </level> </level> </level> <level label="f"> <text>A filing under subsection (c) of this section is subject to the fee required under § 2–112(a)(13) of this article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-144" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer that holds a certificate of authority in the State and provides health insurance in the State;</text> </level> <level label="ii"> <text>a health maintenance organization that is licensed to operate in the State;</text> </level> <level label="iii"> <text>a nonprofit health service plan that is licensed to operate in the State; or</text> </level> <level label="iv"> <text>any other person or organization that provides health benefit plans subject to State insurance regulation.</text> </level> </level> <level label="3"> <text>“Core treatment” means a standard treatment or course of treatment, therapy, service, or intervention indicated by generally recognized independent standards of current medical practice.</text> </level> <level label="4"> <text>“Health benefit plan” means:</text> <level label="i"> <text>for a large group or blanket plan, a health benefit plan as defined in § 15–1401 of this title;</text> </level> <level label="ii"> <text>for a small group plan, a health benefit plan as defined in § 15–1201 of this title;</text> </level> <level label="iii"> <text>for an individual plan:</text> <level label="1"> <text>a health benefit plan as defined in § 15–1301(l) of this title; or</text> </level> <level label="2"> <text>an individual health benefit plan as defined in § 15–1301(o) of this title;</text> </level> </level> <level label="iv"> <text>short–term limited duration insurance as defined in § 15–1301(s) of this title; or</text> </level> <level label="v"> <text>a student health plan as defined in § 15–1318(a) of this title.</text> </level> </level> <level label="5"> <text>“Medical/surgical benefits” has the meaning stated in 45 C.F.R. § 146.136(a) and 29 C.F.R. § 2590.712(a).</text> </level> <level label="6"> <level label="i"> <text>“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:</text> <level label="1"> <text>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:</text> </level> <level label="A"> <text>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</text> </level> <level label="B"> <text>are listed in the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="ii"> <text>“Mental health benefits” does not include medical/surgical benefits or substance use disorder benefits.</text> </level> </level> <level label="7"> <text>“Nonquantitative treatment limitation” means treatment limitations as defined in 45 C.F.R. § 146.136(a) and 29 C.F.R. § 2590.712(a).</text> </level> <level label="8"> <level label="i"> <text>“Parity Act” means the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, as amended.</text> </level> <level label="ii"> <text>“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.</text> </level> </level> <level label="9"> <text>“Parity Act classification” means:</text> <level label="i"> <text>inpatient in–network benefits;</text> </level> <level label="ii"> <text>inpatient out–of–network benefits;</text> </level> <level label="iii"> <text>outpatient in–network benefits;</text> </level> <level label="iv"> <text>outpatient out–of–network benefits;</text> </level> <level label="v"> <text>prescription drug benefits; and</text> </level> <level label="vi"> <text>emergency care benefits.</text> </level> </level> <level label="10"> <text>“Product” has the meaning stated in § 15–1309(a)(3) of this title.</text> </level> <level label="11"> <level label="i"> <text>“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:</text> <level label="1"> <text>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:</text> </level> <level label="A"> <text>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</text> </level> <level label="B"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="ii"> <text>“Substance use disorder benefits” does not include medical/surgical benefits or mental health benefits.</text> </level> </level> </level> <level label="b"> <text>This section applies to a carrier that delivers or issues for delivery a health benefit plan in the State.</text> </level> <level label="c"> <level label="1"> <text>Each carrier subject to this section shall:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <level label="1"> <text>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</text> </level> <level label="2"> <text>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;</text> </level> </level> <level label="iv"> <text>provide the comparative analysis, including the evaluation of relevant data, for each nonquantitative treatment limitation requested by the Commissioner within:</text> <level label="1"> <text>15 working days after a written request; or</text> </level> <level label="2"> <text>if adopted by the federal government, less than 15 working days to align with the federal rule or regulation;</text> </level> </level> <level label="v"> <text>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</text> </level> <level label="vi"> <text>submit the reports required under paragraph (2) of this subsection.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>The report submitted under paragraph (2) of this subsection shall include the following information:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="4"> <text>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:</text> <level label="i"> <text>the statement required under paragraph (3)(iii) of this subsection shall note the exception and identify the plan; and</text> </level> <level label="ii"> <text>the carrier shall submit a separate comparative analysis for the selected nonquantitative treatment limitations for the plan.</text> </level> </level> <level label="5"> <level label="i"> <text>In selecting the nonquantitative treatment limitations required to be included for each reporting period, the Commissioner:</text> <level label="1"> <text>shall prioritize the nonquantitative treatment limitations identified by the Commissioner as having the greatest impact on member access to care;</text> </level> <level label="2"> <text>shall review the same subset of nonquantitative treatment limitations for each carrier report; and</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="ii"> <text>Of the five selected nonquantitative treatment limitations:</text> <level label="1"> <text>not more than two may be for utilization review; and</text> </level> <level label="2"> <text>at least one must be for network composition, including reimbursement rate setting.</text> </level> </level> </level> <level label="6"> <text>A finding of noncompliance for a product shall apply to all plans within the product.</text> </level> <level label="7"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <text>written; and</text> </level> <level label="ii"> <text>in operation.</text> </level> </level> <level label="2"> <text>The comparative analysis of the nonquantitative treatment limitations selected under subsection (c)(5) of this section shall:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>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</text> </level> <level label="iv"> <text>include all information required under the Parity Act and any State regulations adopted under subsection (o) of this section.</text> </level> </level> <level label="3"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> <level label="iii"> <text>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:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> </level> <level label="4"> <text>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.</text> </level> </level> <level label="e"> <text>In providing the analysis required under subsection (d) of this section, a carrier shall:</text> <level label="1"> <text>identify the factors used to determine that a nonquantitative treatment limitation will apply to a benefit, including:</text> <level label="i"> <text>the sources for the factors; and</text> </level> <level label="ii"> <text>if a factor was given more weight than another, the reason for the difference in weighting;</text> </level> </level> <level label="2"> <text>identify and define the specific evidentiary standards used to define the factors and any other evidence relied on in designing each nonquantitative treatment limitation;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>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;</text> </level> <level label="5"> <text>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;</text> </level> <level label="6"> <text>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;</text> </level> <level label="7"> <text>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</text> </level> <level label="8"> <text>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:</text> <level label="i"> <text>the criteria for a medical necessity determination;</text> </level> <level label="ii"> <text>reasons for a denial of benefits; and</text> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="f"> <text>The Commissioner shall:</text> <level label="1"> <text>develop additional standardized data templates:</text> <level label="i"> <text>to evaluate the comparative analysis of nonquantitative treatment limitations in operation; and</text> </level> <level label="ii"> <text>that meet or exceed any minimum requirements for data reporting specified in federal regulations;</text> </level> </level> <level label="2"> <text>require each carrier subject to this section to submit:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>a separate data template for any plans described in subsection (c)(4) of this section; and</text> </level> </level> <level label="3"> <text>post the data templates on the Administration’s website for a comment period of not less than 30 days before adoption.</text> </level> </level> <level label="g"> <text>The reports required under this section shall:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>be submitted by the carrier that issues or delivers the product;</text> </level> <level label="3"> <text>be prepared in coordination with any entity the carrier contracts with to provide mental health benefits and substance use disorder benefits;</text> </level> <level label="4"> <text>contain a statement, signed by a corporate officer, attesting to the accuracy of the information contained in the report;</text> </level> <level label="5"> <text>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</text> </level> <level label="6"> <text>exclude any identifying information of any plan member.</text> </level> </level> <level label="h"> <level label="1"> <text>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:</text> <level label="i"> <text>identify the particular information the disclosure of which the carrier requests be denied; and</text> </level> <level label="ii"> <text>cite the statutory authority under the Public Information Act that authorizes denial of access to the information.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> </level> <level label="i"> <level label="1"> <text>The Commissioner shall:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>within 90 days after the notice of noncompliance is issued, allow the carrier to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>reprocess any claims that were improperly denied, in whole or in part, because of the noncompliance.</text> </level> </level> </level> <level label="2"> <text>The Commissioner may require carriers to complete data templates for a nonquantitative treatment limitation more frequently than every 2 years.</text> </level> </level> <level label="j"> <level label="1"> <text>If the Commissioner finds that the carrier failed to submit a complete report required under this section, the Commissioner may:</text> <level label="i"> <text>take action authorized under paragraph (2) of this subsection;</text> </level> <level label="ii"> <text>in accordance with § 2–208 of this article, charge the carrier for any additional expenses incurred by the Commissioner to review additional reports;</text> </level> <level label="iii"> <text>impose a penalty for each day that the carrier fails to submit information required by the Commissioner to evaluate compliance; or</text> </level> <level label="iv"> <text>impose any penalty or take any action as authorized:</text> <level label="1"> <text>for an insurer, nonprofit health service plan, or any other person subject to this section, under this article; or</text> </level> <level label="2"> <text>for a health maintenance organization, under this article or the Health – General Article.</text> </level> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>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:</text> <level label="1"> <text>modify the conduct or practice as specified by the Commissioner;</text> </level> <level label="2"> <text>cease the conduct or practice; or</text> </level> <level label="3"> <text>submit periodic data related to the conduct or practice; or</text> </level> </level> <level label="ii"> <text>subject to paragraph (3) of this subsection, require the carrier to perform a new comparative analysis.</text> </level> </level> <level label="3"> <text>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:</text> <level label="i"> <text>use applicable quantitative thresholds for the evidentiary standard; or</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="4"> <text>Subsection (i)(1)(iii) of this section does not apply to the failure of a carrier to submit a complete report.</text> </level> </level> <level label="k"> <text>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:</text> <level label="1"> <text>issue an administrative order that requires:</text> <level label="i"> <text>the carrier or an entity delegated by the carrier to cease the noncompliant conduct or practice; or</text> </level> <level label="ii"> <text>the carrier to provide a payment that has been denied improperly because of the noncompliance; or</text> </level> </level> <level label="2"> <text>impose any other penalty or take any action as authorized:</text> <level label="i"> <text>for an insurer, nonprofit health service plan, or any other person subject to this section, under this article; or</text> </level> <level label="ii"> <text>for a health maintenance organization, under this article or the Health – General Article.</text> </level> </level> </level> <level label="l"> <level label="1"> <text>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:</text> <level label="i"> <text>in any review conducted by the Commissioner under this section; or</text> </level> <level label="ii"> <text>in any complaint investigation or market conduct action undertaken by the Commissioner that involves the application of the Parity Act.</text> </level> </level> <level label="2"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>Subsection (i)(1)(iii) of this section does not apply to a carrier that fails to submit complete Parity Act compliance information.</text> </level> </level> </level> <level label="m"> <text>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.</text> </level> <level label="n"> <text>The Commissioner shall create:</text> <level label="1"> <text>a standard form for entities to submit the reports in accordance with subsection (g)(1) of this section; and</text> </level> <level label="2"> <text>a summary form for entities to post to their websites in accordance with subsection (g)(5) of this section.</text> </level> </level> <level label="o"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-145" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words having the meanings indicated.</text> </level> <level label="2"> <text>“Health savings account” has the meaning stated in § 223 of the Internal Revenue Code.</text> </level> <level label="3"> <text>“High deductible health plan” has the meaning stated in § 223 of the Internal Revenue Code.</text> </level> </level> <level label="b"> <text>A health savings account is established on the first day that an individual becomes covered by a high deductible health plan.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-146" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Blanket health insurance” means the form of health insurance described in § 15–305 of this title.</text> </level> <level label="3"> <text>“Health benefit plan” means:</text> <level label="i"> <text>an individual health benefit plan as defined in § 15–1301(o) of this title;</text> </level> <level label="ii"> <text>a health benefit plan as defined in § 15–1201 of this title; or</text> </level> <level label="iii"> <text>a health benefit plan as defined in § 15–1401 of this title.</text> </level> </level> <level label="4"> <text>“Short–term limited duration insurance” has the meaning stated in § 15–1301(s) of this title.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>The Commissioner may enforce this section under any applicable provisions of this article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-148" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-01" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“Carrier” means:</text> <level label="1"> <text>an insurer that holds a certificate of authority in the State and provides health insurance in the State;</text> </level> <level label="2"> <text>a health maintenance organization that is licensed to operate in the State;</text> </level> <level label="3"> <text>a nonprofit health service plan that is licensed to operate in the State; or</text> </level> <level label="4"> <text>any other person or organization that provides health benefit plans subject to State insurance regulation.</text> </level> </level> <level label="c"> <text>“Child” means:</text> <level label="1"> <text>a natural child, a stepchild, a foster child, or an adopted child of the insured; or</text> </level> <level label="2"> <text>a child placed with the insured for legal adoption.</text> </level> </level> <level label="d"> <text>“Essential health benefit” means a health benefit that:</text> <level label="1"> <text>meets the criteria established under § 1302(b) of the Affordable Care Act; or</text> </level> <level label="2"> <text>if the Commissioner adopts regulations as described in § 15–1A–04 of this subtitle, meets the criteria established by the adopted regulations.</text> </level> </level> <level label="e"> <text>“Grandfathered plan” means a health benefit plan that:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>if the Commissioner adopts regulations as described in § 15–1A–03 of this subtitle, meets the criteria established by the adopted regulations.</text> </level> </level> <level label="f"> <text>“Group plan” means a small group plan or a large group plan.</text> </level> <level label="g"> <text>“Health benefit plan” means an individual plan, a small group plan, or a large group plan.</text> </level> <level label="h"> <text>“Individual plan” means an individual health benefit plan as defined in § 15–1301(o) of this title.</text> </level> <level label="i"> <text>“Insured individual” means:</text> <level label="1"> <text>an insured, an enrollee, a subscriber, a participant, a member, or a beneficiary of a health benefit plan; or</text> </level> <level label="2"> <text>any covered dependent of a health benefit plan.</text> </level> </level> <level label="j"> <text>“Large group plan” means a health benefit plan as defined in § 15–1401 of this title.</text> </level> <level label="k"> <text>“Small group plan” means a health benefit plan as defined in § 15–1201 of this title.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-02" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>The Commissioner may enforce:</text> <level label="1"> <text>the provisions of this subtitle; and</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>coverage of children up to the age of 26 years;</text> </level> <level label="ii"> <text>preexisting condition exclusions;</text> </level> <level label="iii"> <text>policy rescissions;</text> </level> <level label="iv"> <text>bona fide wellness programs;</text> </level> <level label="v"> <text>lifetime limits;</text> </level> <level label="vi"> <text>annual limits for essential benefits;</text> </level> <level label="vii"> <text>waiting periods;</text> </level> <level label="viii"> <text>designation of primary care providers;</text> </level> <level label="ix"> <text>access to obstetrical and gynecological services;</text> </level> <level label="x"> <text>emergency services;</text> </level> <level label="xi"> <text>summary of benefits and coverage explanation;</text> </level> <level label="xii"> <text>minimum loss ratio requirements and premium rebates;</text> </level> <level label="xiii"> <text>disclosure of information;</text> </level> <level label="xiv"> <text>annual limitations on cost–sharing;</text> </level> <level label="xv"> <text>child–only plan offerings in the individual market;</text> </level> <level label="xvi"> <text>minimum benefit requirements for catastrophic plans;</text> </level> <level label="xvii"> <text>health insurance premium rates;</text> </level> <level label="xviii"> <text>coverage for individuals participating in approved clinical trials;</text> </level> <level label="xix"> <text>contract requirements for stand–alone dental plans sold on the Maryland Health Benefit Exchange;</text> </level> <level label="xx"> <text>guaranteed availability of coverage;</text> </level> <level label="xxi"> <text>prescription drug benefit requirements; and</text> </level> <level label="xxii"> <text>preventive and wellness services and chronic disease management.</text> </level> </level> </level> <level label="b"> <text>The Commissioner may enforce the provisions identified under subsection (a) of this section under any applicable powers granted to the Commissioner under this article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-03" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>For purposes of this subtitle, to the extent necessary, the Commissioner shall adopt regulations that:</text> <level label="1"> <text>establish criteria that a health benefit plan must meet to be considered a grandfathered plan; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>Subtitle 12 of this title;</text> </level> <level label="2"> <text>Subtitle 13 of this title; or</text> </level> <level label="3"> <text>Subtitle 14 of this title.</text> </level> </level> <level label="c"> <level label="1"> <text>Except as provided in paragraph (2) of this subsection, the provisions of this subtitle do not apply to a grandfathered plan.</text> </level> <level label="2"> <level label="i"> <text>The following provisions apply to all grandfathered plans:</text> <level label="1"> <text>the provisions of § 15–1A–08 of this subtitle related to health benefit plans that provide dependent coverage of a child;</text> </level> <level label="2"> <text>the provisions of § 15–1A–11 of this subtitle related to the prohibition on establishing lifetime limits on the dollar value of benefits;</text> </level> <level label="3"> <text>the provisions of § 15–1A–12 of this subtitle related to waiting periods;</text> </level> <level label="4"> <text>the provisions of § 15–1A–13 of this subtitle related to choice of provider;</text> </level> <level label="5"> <text>the provisions of § 15–1A–14 of this subtitle related to coverage of emergency services;</text> </level> <level label="6"> <text>the provisions of § 15–1A–15 of this subtitle related to summary of benefits and coverage requirements;</text> </level> <level label="7"> <text>the provisions of § 15–1A–16 of this subtitle related to medical loss ratio and corresponding reporting and rebate requirements; and</text> </level> <level label="8"> <text>the provisions of § 15–1A–21 of this subtitle related to rescission of a health benefit plan.</text> </level> </level> <level label="ii"> <text>The following provisions apply to all grandfathered plans except grandfathered plans that are individual plans:</text> <level label="1"> <text>the provisions of § 15–1A–05 of this subtitle related to preexisting condition exclusions; and</text> </level> <level label="2"> <text>the provisions of § 15–1A–11 of this subtitle related to the prohibition on establishing annual limits on the dollar value of benefits.</text> </level> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-04" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <text>For purposes of this subtitle, to the extent necessary, the Commissioner shall adopt regulations that:</text> <level label="1"> <text>establish criteria that a health benefit plan must meet to be considered a health benefit plan that covers essential health benefits; and</text> </level> <level label="2"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-05" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>A carrier may not:</text> <level label="1"> <text>exclude or limit benefits because a health condition was present before the effective date of coverage; or</text> </level> <level label="2"> <text>deny coverage because a health condition was present before or on the date of denial.</text> </level> </level> <level label="c"> <text>The prohibition in subsection (b) of this section applies whether or not:</text> <level label="1"> <text>any medical advice, diagnosis, care, or treatment was recommended or received for the condition; or</text> </level> <level label="2"> <text>the health condition was identified as a result of:</text> <level label="i"> <text>a pre–enrollment questionnaire or physical examination given to an individual; or</text> </level> <level label="ii"> <text>a review of records relating to the pre–enrollment period.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-06" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>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:</text> <level label="1"> <text>health condition;</text> </level> <level label="2"> <text>claims experience;</text> </level> <level label="3"> <text>receipt of health care;</text> </level> <level label="4"> <text>medical history;</text> </level> <level label="5"> <text>genetic information;</text> </level> <level label="6"> <text>evidence of insurability including conditions arising out of acts of domestic violence; or</text> </level> <level label="7"> <text>disability.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-07" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>A carrier may determine a premium rate based on:</text> <level label="1"> <text>subject to subsection (c) of this section, age;</text> </level> <level label="2"> <text>geography based on the following contiguous areas of the State:</text> <level label="i"> <text>the Baltimore metropolitan area;</text> </level> <level label="ii"> <text>the District of Columbia metropolitan area;</text> </level> <level label="iii"> <text>Western Maryland; and</text> </level> <level label="iv"> <text>Eastern Maryland and Southern Maryland;</text> </level> </level> <level label="3"> <text>subject to subsection (d) of this section, whether the plan covers an individual or a family; and</text> </level> <level label="4"> <text>subject to subsection (e) of this section, tobacco use.</text> </level> </level> <level label="c"> <level label="1"> <text>In this subsection, “age” means an individual’s age as of the date of issuance or renewal of a health benefit plan.</text> </level> <level label="2"> <text>For individuals who are 21 years of age or older, a premium rate based on age:</text> <level label="i"> <text>may not vary by more than a ratio of 3 to 1 for adults;</text> </level> <level label="ii"> <text>shall provide for 1–year age bands for individuals at least 21 years old and under the age of 64 years; and</text> </level> <level label="iii"> <text>shall provide for a single age band for individuals at least 64 years old.</text> </level> </level> <level label="3"> <text>For individuals who are under the age of 21 years, a premium rate based on age shall:</text> <level label="i"> <text>be actuarially justified and consistent with the uniform age rating curve established in accordance with paragraph (4) of this subsection;</text> </level> <level label="ii"> <text>provide for a single age band for individuals under the age of 15 years; and</text> </level> <level label="iii"> <text>provide for 1–year age bands for individuals at least 15 years old and under the age of 20 years.</text> </level> </level> <level label="4"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="e"> <text>A premium rate based on tobacco use may not vary by more than a ratio of 1.5 to 1.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-08" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-09" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>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:</text> <level label="1"> <text>Subtitle 4 of this title;</text> </level> <level label="2"> <text>§§ 15–1206(c), 15–1208.1, 15–1208.2, 15–1209, and 15–1210 of this title;</text> </level> <level label="3"> <text>§§ 15–1316 and 15–1318 of this title; and</text> </level> <level label="4"> <text>§§ 15–1406 and 15–1406.1 of this title.</text> </level> </level> <level label="b"> <level label="1"> <text>Except as provided in paragraph (2) of this subsection, a carrier may restrict enrollment to open or special enrollment periods.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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</text> </level> </level> <level label="2"> <text>may deny coverage within a service area if the carrier:</text> <level label="i"> <text>demonstrates to the Commissioner that:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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</text> </level> </level> <level label="ii"> <text>does not offer coverage within the service area for at least 180 days after the date the carrier denied coverage in the service area.</text> </level> </level> </level> <level label="d"> <text>A carrier may deny coverage if the carrier:</text> <level label="1"> <text>demonstrates to the Commissioner that:</text> <level label="i"> <text>the carrier does not have the financial reserves necessary to underwrite additional coverage; and</text> </level> <level label="ii"> <text>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</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-10" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>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:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>has been adopted by the Director of the Centers for Disease Control and Prevention; or</text> </level> <level label="ii"> <text>is listed on the Immunization Schedules of the Centers for Disease Control and Prevention for routine use;</text> </level> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>with respect to women:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <level label="1"> <text>In this subsection, “high deductible health plan” has the meaning stated in 26 U.S.C. § 223(c)(2).</text> </level> <level label="2"> <text>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).</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-11" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-12" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1A-13" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <level label="i"> <text>This subsection applies only to an individual who has a child who is an insured individual under the individual’s health benefit plan.</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <level label="i"> <text>This subsection applies only to a carrier that:</text> <level label="1"> <text>provides coverage for obstetrical or gynecological care; and</text> </level> <level label="2"> <text>requires the designation by an insured individual of a participating primary care provider.</text> </level> </level> <level label="ii"> <text>This subsection may not be construed to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>A health care provider that provides obstetrical or gynecological care shall comply with a carrier’s policies and procedures.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-14" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <level label="i"> <text>“Emergency services” means, with respect to an emergency medical condition:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="ii"> <text>“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.</text> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="b"> <text>If a carrier provides or covers any benefits for emergency services in an emergency department of a hospital or freestanding medical facility, the carrier:</text> <level label="1"> <text>may not require prior authorization for the emergency services;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>may not limit what constitutes an emergency medical condition solely on the basis of diagnosis codes; and</text> </level> <level label="4"> <text>may not impose any other term or condition on the coverage for emergency services, except for:</text> <level label="i"> <text>the exclusion or coordination of benefits;</text> </level> <level label="ii"> <text>a waiting period; and</text> </level> <level label="iii"> <text>applicable cost–sharing.</text> </level> </level> </level> <level label="c"> <text>If a health care provider of emergency services does not have a contractual relationship with the carrier to provide emergency services, the carrier:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>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).</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-15" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>This section applies to all grandfathered plans and to every health benefit plan that is not a grandfathered plan.</text> </level> <level label="b"> <level label="1"> <text>A carrier shall compile and provide to consumers a summary of benefits and coverage explanation that:</text> <level label="i"> <text>accurately describes the benefits and coverage under the applicable health benefit plan; and</text> </level> <level label="ii"> <text>except as provided in paragraph (2) of this subsection, complies with the standards under 45 C.F.R. § 147.200.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>To the extent necessary, the Commissioner, in consultation with the Maryland Health Benefit Exchange, shall adopt regulations that:</text> <level label="1"> <text>establish standards for the summary of benefits and coverage; and</text> </level> <level label="2"> <text>are consistent with 45 C.F.R. § 147.200 and any corresponding federal rules and guidance in effect December 31, 2024.</text> </level> </level> <level label="d"> <text>The summary of benefits and coverage shall be presented:</text> <level label="1"> <text>in a uniform format that does not exceed four pages in length and does not include print smaller than 12 point type; and</text> </level> <level label="2"> <text>in a culturally and linguistically appropriate manner that uses terminology understandable by the average insured individual.</text> </level> </level> <level label="e"> <text>The standards developed under subsection (c) of this section shall include:</text> <level label="1"> <text>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:</text> <level label="i"> <text>premium;</text> </level> <level label="ii"> <text>deductible;</text> </level> <level label="iii"> <text>coinsurance;</text> </level> <level label="iv"> <text>copayment;</text> </level> <level label="v"> <text>out–of–pocket limit;</text> </level> <level label="vi"> <text>preferred provider;</text> </level> <level label="vii"> <text>nonpreferred provider;</text> </level> <level label="viii"> <text>out–of–network copayments;</text> </level> <level label="ix"> <text>usual, customary, and reasonable fees;</text> </level> <level label="x"> <text>excluded services;</text> </level> <level label="xi"> <text>grievance and appeals;</text> </level> <level label="xii"> <text>hospitalization;</text> </level> <level label="xiii"> <text>hospital outpatient care;</text> </level> <level label="xiv"> <text>emergency room care;</text> </level> <level label="xv"> <text>physician services;</text> </level> <level label="xvi"> <text>prescription drug coverage;</text> </level> <level label="xvii"> <text>durable medical equipment;</text> </level> <level label="xviii"> <text>home health care;</text> </level> <level label="xix"> <text>skilled nursing care;</text> </level> <level label="xx"> <text>rehabilitation services;</text> </level> <level label="xxi"> <text>hospice services;</text> </level> <level label="xxii"> <text>emergency medical transportation; and</text> </level> <level label="xxiii"> <text>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;</text> </level> </level> <level label="2"> <text>a description of the coverage of a health benefit plan, including cost–sharing for:</text> <level label="i"> <text>each of the categories of the essential health benefits in the State benchmark plan selected in accordance with § 31–116 of this article; and</text> </level> <level label="ii"> <text>other benefits, as identified by the Commissioner;</text> </level> </level> <level label="3"> <text>the exceptions, reductions, and limitations on coverage;</text> </level> <level label="4"> <text>the renewability and continuation of coverage provisions;</text> </level> <level label="5"> <text>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;</text> </level> <level label="6"> <text>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;</text> </level> <level label="7"> <text>a statement that:</text> <level label="i"> <text>the summary of benefits is an outline of the health benefit plan; and</text> </level> <level label="ii"> <text>the language of the health benefit plan should be consulted to determine the governing contractual provisions; and</text> </level> </level> <level label="8"> <text>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.</text> </level> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <level label="1"> <text>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:</text> <level label="i"> <text>an applicant at the time of application; and</text> </level> <level label="ii"> <text>an insured individual before the time of enrollment or reenrollment, as applicable.</text> </level> </level> <level label="2"> <text>A carrier may provide a summary of benefits and coverage explanation as required under paragraph (1) of this subsection in paper or electronic form.</text> </level> </level> <level label="h"> <text>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.</text> </level> <level label="i"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>A failure with respect to each insured individual shall constitute a separate offense for purposes of this subsection.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-16" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <level label="1"> <text>For purposes of this section, “medical loss ratio”:</text> <level label="i"> <text>has the meaning established in 45 C.F.R. § 158.221; or</text> </level> <level label="ii"> <text>if the Commissioner adopts regulations as described in paragraph (2) of this subsection, has the meaning established by the adopted regulations.</text> </level> </level> <level label="2"> <text>To the extent necessary, the Commissioner shall adopt regulations that:</text> <level label="i"> <text>establish a definition for “medical loss ratio”; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="b"> <text>This section applies to all grandfathered plans and to every health benefit plan that is not a grandfathered plan.</text> </level> <level label="c"> <text>The minimum acceptable medical loss ratio is:</text> <level label="1"> <text>for the large group market, 85% or a higher percentage as determined by the Commissioner in regulations; and</text> </level> <level label="2"> <text>for the small group market and individual market, 80% or a higher percentage as determined by the Commissioner in regulations.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>If the Commissioner adopts regulations as described in subsection (e) of this section, each carrier shall comply with the requirements in the adopted regulations.</text> </level> </level> <level label="e"> <text>To the extent necessary, the Commissioner shall adopt regulations that:</text> <level label="1"> <text>establish requirements for calculating medical loss ratios and related reporting and rebate requirements; and</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-17" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <level label="1"> <text>This section may not be construed to require a carrier to disclose information that is proprietary and trade secret information under applicable law.</text> </level> <level label="2"> <text>This section applies only to carriers offering an individual plan or a small group plan.</text> </level> </level> <level label="b"> <text>A carrier shall disclose to an individual or employer, as applicable, the following information:</text> <level label="1"> <text>the carrier’s right to change premium rates and the factors that may affect changes in premium rates; and</text> </level> <level label="2"> <text>the benefits and premiums available under all health benefit plans for which the employer or individual is qualified.</text> </level> </level> <level label="c"> <text>The carrier shall make the disclosure required under subsection (b) of this section:</text> <level label="1"> <text>as part of its solicitation and sales material; or</text> </level> <level label="2"> <text>if the information is requested by the individual or employer.</text> </level> </level> <level label="d"> <text>Information disclosed in accordance with subsection (b) of this section shall be:</text> <level label="1"> <text>provided in a manner determined to be understandable by the average employer or individual; and</text> </level> <level label="2"> <text>sufficient to reasonably inform the employer or individual of the employer’s or individual’s rights and obligations under the health benefit plan.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-18" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>A carrier may offer a catastrophic plan in the individual market in accordance with the requirements of this section.</text> </level> <level label="b"> <text>A catastrophic plan may be offered only to individuals who:</text> <level label="1"> <text>are under the age of 30 years before the beginning of the plan year; or</text> </level> <level label="2"> <text>hold certification for a hardship exemption or an affordability exemption as required in subsection (c) of this section.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <text>To the extent necessary, the Maryland Health Benefit Exchange shall adopt regulations that:</text> <level label="1"> <text>establish a process for issuing hardship exemptions and affordability exemptions; and</text> </level> <level label="2"> <text>are consistent with 42 U.S.C. § 5000A and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024.</text> </level> </level> <level label="e"> <level label="1"> <text>Subject to paragraph (2) of this subsection, a catastrophic plan shall provide coverage for essential health benefits.</text> </level> <level label="2"> <text>A catastrophic plan shall require a deductible that:</text> <level label="i"> <text>is equal to the annual limit on cost–sharing described in § 15–1A–19 of this subtitle;</text> </level> <level label="ii"> <text>applies to essential health benefits;</text> </level> <level label="iii"> <text>does not apply to at least three primary care visits each plan year; and</text> </level> <level label="iv"> <text>does not apply to any covered benefits for which a deductible is prohibited under this title.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-19" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <level label="1"> <text>In this section, “cost–sharing” means any expenditure required by or on behalf of an insured individual with respect to essential health benefits.</text> </level> <level label="2"> <text>“Cost–sharing” includes:</text> <level label="i"> <text>deductibles, coinsurance, copayments, or similar charges; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="3"> <text>“Cost–sharing” does not include premiums, balance billing amounts for nonnetwork providers, or spending for noncovered services.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>If the Commissioner adopts regulations as described in subsection (c) of this section, each carrier shall comply with the adopted regulations.</text> </level> </level> <level label="c"> <text>To the extent necessary, the Commissioner shall adopt regulations that:</text> <level label="1"> <text>establish annual limitations on cost–sharing; and</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-20" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <level label="1"> <text>This section applies only to individual plans and small group plans.</text> </level> <level label="2"> <text>The requirements in this section are in addition to and not in substitution of any other requirements of law related to prescription drug benefits.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>To the extent necessary, the Commissioner shall adopt regulations that:</text> <level label="1"> <text>establish criteria to determine whether an individual plan or a small group plan provides prescription drug essential health benefit coverage; and</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-21" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <text>This section applies to all grandfathered plans and to every health benefit plan that is not a grandfathered plan.</text> </level> <level label="b"> <level label="1"> <text>Subject to § 15–1106 of this title, a carrier may not rescind the coverage under a health benefit plan unless:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>except as provided in paragraph (2) of this subsection, the carrier complies with 45 C.F.R. § 147.128.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>To the extent necessary, the Commissioner shall adopt regulations that:</text> <level label="1"> <text>establish requirements that a carrier shall comply with to rescind coverage under subsection (b) of this section; and</text> </level> <level label="2"> <text>are consistent with 45 C.F.R. § 147.128 and any federal rules and guidance as those provisions were in effect December 31, 2024.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1A-22" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Gender identity” has the meaning stated in § 20–101 of the State Government Article.</text> </level> <level label="3"> <text>“Sexual orientation” has the meaning stated in § 20–101 of the State Government Article.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>The Commissioner and the Commission on Civil Rights shall enforce the provisions of this section as provided for in § 2–202 of this article.</text> </level> <level label="f"> <text>The Commissioner may adopt regulations necessary to carry out this section consistent with federal statutes, rules, and guidance in effect on December 31, 2024.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-201" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>Each policy of health insurance shall state explicitly:</text> <level label="1"> <text>any consideration, including the entire amount of money, given for the policy; and</text> </level> <level label="2"> <text>the time when the health insurance takes effect and terminates.</text> </level> </level> <level label="c"> <level label="1"> <text>Except as provided in paragraph (2) of this subsection, each policy of health insurance shall purport to insure only one individual.</text> </level> <level label="2"> <text>On application by an adult member of a family, a policy of health insurance may insure, originally or by subsequent amendment:</text> <level label="i"> <text>the applicant, who is deemed the policyholder; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The style, arrangement, and overall appearance of a policy may not give undue prominence to any part of the text.</text> </level> <level label="3"> <text>Each printed part of the text and of any endorsements or attached papers shall be printed plainly in lightfaced type:</text> <level label="i"> <text>of a style in general use; and</text> </level> <level label="ii"> <text>in a size that is uniform and not less than 10 point with a lower case unspaced alphabet length not less than 120 point.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>The exceptions and reductions of indemnity shall be set forth in the policy.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>with the benefit provisions to which they apply; or</text> </level> <level label="ii"> <text>under an appropriate caption such as “Exceptions” or “Exceptions and Reductions”.</text> </level> </level> <level label="3"> <text>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.</text> </level> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="h"> <level label="1"> <text>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:</text> <level label="i"> <text>the policy may be surrendered to the insurer for cancellation within 10 days after the date the policy is delivered to the insured; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>The insured shall notify the insurer of the cancellation in writing.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="i"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-202" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>Except as otherwise provided in this section, each policy of health insurance that is delivered or issued for delivery in the State:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>shall contain each mandatory provision and any optional provision that is used:</text> <level label="i"> <text>in the order in which those provisions appear in this subtitle; or</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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:</text> <level label="1"> <text>omit from the policy the inapplicable provision or part of the provision; or</text> </level> <level label="2"> <text>modify the inconsistent provision or part of the provision to make it consistent with the coverage provided by the policy.</text> </level> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-203" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <text>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:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>that a refusal to renew shall be without prejudice to any claim that originates while the policy is in effect;</text> </level> <level label="3"> <text>that a renewal may not be refused solely because of a change in the health or physical or mental condition of the insured; and</text> </level> <level label="4"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-204" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-205" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>A policy of a foreign insurer or alien insurer that is delivered or issued for delivery in the State may contain a provision that:</text> <level label="1"> <text>is not less favorable to the insured or beneficiary than the provisions of this subtitle; and</text> </level> <level label="2"> <text>is required by the law of the state or country under which the foreign insurer or alien insurer is organized.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-206" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-207" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <text>Each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </section> <section article="gin" article_name="Insurance" number="15-208" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>Except as provided in subsection (c) of this section, each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> <level label="2"> <text>“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.”</text> </level> </level> <level label="b"> <text>The first provision set forth in subsection (a) of this section does not:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <text>This subsection applies only to a policy that the insured may continue in effect subject to its terms by the timely payment of premiums:</text> <level label="i"> <text>until the insured is at least 50 years old; or</text> </level> <level label="ii"> <text>if the policy is issued after the insured is 44 years old, for at least 5 years after its date of issue.</text> </level> </level> <level label="2"> <text>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”:</text> <text>“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.”</text> </level> <level label="3"> <text>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”.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-209" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <level label="1"> <text>Subject to subsection (b) of this section, each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </level> <level label="2"> <text>A policy shall provide a grace period of 31 days if the policy:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>does not require a formal request by the policyholder to change the mode of premium payment.</text> </level> </level> </level> <level label="b"> <text>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:</text> <text>“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.”</text> </level> </section> <section article="gin" article_name="Insurance" number="15-210" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>Each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>until the insured is at least 50 years old; or</text> </level> <level label="2"> <text>if the policy is issued after the insured is 44 years old, for at least 5 years after its date of issue.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-211" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>Each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </level> <level label="b"> <text>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:</text> <text>“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.”</text> </level> </section> <section article="gin" article_name="Insurance" number="15-212" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <text>Each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </section> <section article="gin" article_name="Insurance" number="15-213" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <text>Except as provided in § 12–102(c) of this article, each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </section> <section article="gin" article_name="Insurance" number="15-214" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>Each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </level> <level label="b"> <text>A policy is considered to provide for periodic payment for loss only if the policy contains a specific statement to that effect.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-215" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>Each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>“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.”</text> </level> <level label="3"> <text>“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.”</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-216" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <text>Each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </section> <section article="gin" article_name="Insurance" number="15-217" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <text>Each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </section> <section article="gin" article_name="Insurance" number="15-218" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>Subject to subsection (b) of this section, each policy of health insurance shall contain the following provision:</text> <text>“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.”</text> </level> <level label="b"> <text>An insurer may choose to omit from the provision set forth in subsection (a) of this section the clause:</text> <text>“Unless the insured makes an irrevocable designation of beneficiary”.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-219" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <text>A policy of health insurance may contain the following provision:</text> <text>“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.”</text> </section> <section article="gin" article_name="Insurance" number="15-220" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <text>A policy of health insurance may contain the following provision:</text> <text>“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.”</text> </section> <section article="gin" article_name="Insurance" number="15-221" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>A policy of health insurance may contain the following provision:</text> <text>“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.”</text> </level> <level label="b"> <text>A policy of health insurance may substitute the following provision for the provision set forth in subsection (a) of this section:</text> <text>“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.”</text> </level> </section> <section article="gin" article_name="Insurance" number="15-222" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>A policy of health insurance may contain the following provision:</text> <text>“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.”</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The insurer may include in the provision set forth in subsection (a) of this section a definition of “other valid coverage” if the definition:</text> <level label="i"> <text>is approved as to form by the Commissioner; and</text> </level> <level label="ii"> <text>is limited to:</text> <level label="1"> <text>coverage provided by organizations subject to regulation by insurance law or insurance authorities of this State, another state, or a province of Canada;</text> </level> <level label="2"> <text>coverage provided by hospital or medical service organizations; and</text> </level> <level label="3"> <text>any other coverage that the Commissioner may approve for inclusion.</text> </level> </level> </level> <level label="3"> <text>Unless defined otherwise, “other valid coverage” does not include:</text> <level label="i"> <text>group insurance or automobile medical payments insurance;</text> </level> <level label="ii"> <text>coverage provided by hospital or medical service organizations; or</text> </level> <level label="iii"> <text>coverage provided by union welfare plans or by employer or employee benefit organizations.</text> </level> </level> <level label="4"> <text>“Other valid coverage” may not include third party liability coverage.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-223" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>A policy of health insurance may contain the following provision:</text> <text>“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.”</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The insurer may include in the provision set forth in subsection (a) of this section a definition of “other valid coverage” if the definition:</text> <level label="i"> <text>is approved as to form by the Commissioner; and</text> </level> <level label="ii"> <text>is limited to:</text> <level label="1"> <text>coverage provided by organizations subject to regulation by insurance law or insurance authorities of this State, another state, or a province of Canada; and</text> </level> <level label="2"> <text>any other coverage the Commissioner may approve for inclusion.</text> </level> </level> </level> <level label="3"> <text>Unless defined otherwise, “other valid coverage” does not include:</text> <level label="i"> <text>group insurance; or</text> </level> <level label="ii"> <text>coverage provided by union welfare plans or by employer or employee benefit organizations.</text> </level> </level> <level label="4"> <text>“Other valid coverage” may not include third party liability coverage.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-224" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <level label="a"> <text>A policy of health insurance may contain the following provision:</text> <text>“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.”</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>until the insured is at least 50 years old; or</text> </level> <level label="2"> <text>if the policy is issued after the insured is 44 years old, for at least 5 years after its date of issue.</text> </level> </level> <level label="c"> <level label="1"> <text>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:</text> <level label="i"> <text>is approved as to form by the Commissioner;</text> </level> <level label="ii"> <text>is limited to:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>any other coverage that the Commissioner may approve for inclusion; or</text> </level> <level label="3"> <text>a combination of these coverages.</text> </level> </level> </level> <level label="2"> <text>Unless defined otherwise, “valid loss-of-time coverage” does not include:</text> <level label="i"> <text>coverage provided for the insured under a compulsory benefit statute, including a workers’ compensation or employer’s liability statute; or</text> </level> <level label="ii"> <text>coverage provided by union welfare plans or by employer or employee benefit organizations.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-225" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <text>A policy of health insurance may contain the following provision:</text> <text>“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.”</text> </section> <section article="gin" article_name="Insurance" number="15-226" title_number="15" title_name="Health Insurance" subtitle_number="2" subtitle_name="Individual Health Insurance Policy Forms and Provisions"> <text>A policy of health insurance may contain the following provision:</text> <text>“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.”</text> </section> <section article="gin" article_name="Insurance" number="15-301" title_number="15" title_name="Health Insurance" subtitle_number="3" subtitle_name="Group and Blanket Health Insurance Policy Forms and Provisions"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“Blanket health insurance” means the form of health insurance described in § 15-305 of this subtitle.</text> </level> <level label="c"> <text>“Group health insurance” means the form of health insurance described in § 15-302 of this subtitle.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-302" title_number="15" title_name="Health Insurance" subtitle_number="3" subtitle_name="Group and Blanket Health Insurance Policy Forms and Provisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <level label="i"> <text>In this subsection, “employee” may include:</text> <level label="1"> <text>an officer or manager of the employer;</text> </level> <level label="2"> <text>a sole proprietor if the employer is a sole proprietorship;</text> </level> <level label="3"> <text>a partner if the employer is a partnership;</text> </level> <level label="4"> <text>an officer, manager, or employee of a corporation that is an affiliate or subsidiary of the employer;</text> </level> <level label="5"> <text>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;</text> </level> <level label="6"> <text>a retired employee;</text> </level> <level label="7"> <text>an elected or appointed official of a public body, but only if the policy is issued to insure employees of the public body; and</text> </level> <level label="8"> <text>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.</text> </level> </level> <level label="ii"> <text>“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.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>The employer or trustees to which the policy is issued are deemed the policyholder.</text> </level> </level> <level label="c"> <level label="1"> <text>In this subsection, “employee” may include a retired employee.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>In this subsection, “employee” may include:</text> <level label="i"> <text>an officer or manager of the employer;</text> </level> <level label="ii"> <text>a sole proprietor if the employer is a sole proprietorship;</text> </level> <level label="iii"> <text>a partner if the employer is a partnership;</text> </level> <level label="iv"> <text>a retired employee; and</text> </level> <level label="v"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>The trustees to which the policy is issued are deemed the policyholder.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-304" title_number="15" title_name="Health Insurance" subtitle_number="3" subtitle_name="Group and Blanket Health Insurance Policy Forms and Provisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>A policy of group health insurance may not require that hospital, nursing, medical, or surgical services be provided by a particular hospital or person.</text> </level> <level label="c"> <text>A direct payment made under subsection (a) of this section discharges the insurer’s obligation with respect to the amount paid.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-305" title_number="15" title_name="Health Insurance" subtitle_number="3" subtitle_name="Group and Blanket Health Insurance Policy Forms and Provisions"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The person to which or in the name of which a policy or contract is issued is deemed the policyholder.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>A policy or contract of blanket health insurance may be issued to a sports team or its sponsors, to cover members, officials, and supervisors.</text> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-306" title_number="15" title_name="Health Insurance" subtitle_number="3" subtitle_name="Group and Blanket Health Insurance Policy Forms and Provisions"> <level label="a"> <text>An insurer that is authorized to issue policies of health insurance in the State may issue blanket health insurance.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-308" title_number="15" title_name="Health Insurance" subtitle_number="3" subtitle_name="Group and Blanket Health Insurance Policy Forms and Provisions"> <level label="a"> <text>An individual who is covered under a policy or contract of blanket health insurance may not be required to complete an individual application.</text> </level> <level label="b"> <text>An insurer need not provide a certificate to each individual covered under a policy of blanket health insurance.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-309" title_number="15" title_name="Health Insurance" subtitle_number="3" subtitle_name="Group and Blanket Health Insurance Policy Forms and Provisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>A policy of blanket health insurance may not require that hospital, nursing, medical, or surgical services be provided by a particular hospital or person.</text> </level> <level label="3"> <text>A direct payment made under paragraph (1) of this subsection discharges the insurer’s obligation with respect to the amount paid.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-310" title_number="15" title_name="Health Insurance" subtitle_number="3" subtitle_name="Group and Blanket Health Insurance Policy Forms and Provisions"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-401" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <text>In this section, “date of adoption” means the earlier of:</text> <level label="1"> <text>a judicial decree of adoption; or</text> </level> <level label="2"> <text>the assumption of custody, pending adoption, of a prospective adoptive child by a prospective adoptive parent.</text> </level> </level> <level label="b"> <level label="1"> <text>This subsection applies to:</text> <level label="i"> <text>each individual health insurance policy that:</text> <level label="1"> <text>is delivered, issued for delivery, or renewed in the State;</text> </level> <level label="2"> <text>provides coverage on an expense–incurred basis; and</text> </level> <level label="3"> <text>provides coverage for a family member of the insured;</text> </level> </level> <level label="ii"> <text>each group health insurance policy, including a contract issued by a nonprofit health service plan, that:</text> <level label="1"> <text>is delivered, issued for delivery, or renewed in the State;</text> </level> <level label="2"> <text>provides coverage on an expense–incurred basis for employees of an employer or employers or members of a union or unions; and</text> </level> <level label="3"> <text>provides coverage for a family member of a covered employee or member;</text> </level> </level> <level label="iii"> <text>each individual service or indemnity contract that:</text> <level label="1"> <text>is delivered, issued for delivery, or renewed in the State by a nonprofit health service plan; and</text> </level> <level label="2"> <text>provides coverage for a family member of the subscriber;</text> </level> </level> <level label="iv"> <text>each individual contract that:</text> <level label="1"> <text>is delivered, issued for delivery, or renewed in the State by a health maintenance organization; and</text> </level> <level label="2"> <text>provides coverage for a family member of the subscriber; and</text> </level> </level> <level label="v"> <text>each group contract that:</text> <level label="1"> <text>is delivered, issued for delivery, or renewed in the State by a health maintenance organization;</text> </level> <level label="2"> <text>provides coverage for employees of an employer or employers or members of a union or unions; and</text> </level> <level label="3"> <text>provides coverage for a family member of the covered employee or member.</text> </level> </level> </level> <level label="2"> <text>Each policy or contract subject to this subsection shall provide that the health insurance benefits applicable:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>for a minor for whom guardianship is granted by court or testamentary appointment shall be payable from the date of appointment.</text> </level> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>Each insurer, nonprofit health service plan, or health maintenance organization that issues a policy or contract that does not provide family members’ coverage shall:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>inform the insured, subscriber, or member of the right and conditions to purchase family members’ coverage under this section.</text> </level> </level> <level label="e"> <text>To be eligible for coverage under this section:</text> <level label="1"> <text>a grandchild must be a dependent, and in the court–ordered custody, of the insured, subscriber, or member; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-402" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>each individual or group health insurance policy that is issued in the State; and</text> </level> <level label="2"> <text>each contract that is issued in the State by a nonprofit health service plan or a health maintenance organization.</text> </level> </level> <level label="b"> <level label="1"> <text>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:</text> <level label="i"> <text>is unmarried;</text> </level> <level label="ii"> <text>is chiefly dependent for support on the employee, member, or other covered individual; and</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>To be eligible for coverage under this section:</text> <level label="1"> <text>a grandchild must be a dependent, and in the court–ordered custody, of the employee, member, or other covered individual; and</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-403" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>each individual health insurance policy that:</text> <level label="i"> <text>provides coverage on an expense–incurred basis; and</text> </level> <level label="ii"> <text>provides coverage for a family member of the insured;</text> </level> </level> <level label="2"> <text>each group health insurance policy that:</text> <level label="i"> <text>provides coverage on an expense–incurred basis for employees of an employer or employers or members of a union or unions; and</text> </level> <level label="ii"> <text>provides coverage for a family member of a covered employee or member;</text> </level> </level> <level label="3"> <text>each individual service or indemnity contract that:</text> <level label="i"> <text>is issued by a nonprofit health service plan; and</text> </level> <level label="ii"> <text>provides coverage for a family member of the subscriber;</text> </level> </level> <level label="4"> <text>each individual contract that:</text> <level label="i"> <text>is issued by a health maintenance organization; and</text> </level> <level label="ii"> <text>provides coverage for a family member of the subscriber; and</text> </level> </level> <level label="5"> <text>each group contract that:</text> <level label="i"> <text>is issued by a health maintenance organization;</text> </level> <level label="ii"> <text>provides coverage for employees of an employer or employers or members of a union or unions; and</text> </level> <level label="iii"> <text>provides coverage for a family member of the covered employee or member.</text> </level> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>is unmarried;</text> </level> <level label="2"> <text>is in the court–ordered custody of the insured, subscriber, employee, or member;</text> </level> <level label="3"> <text>resides with the insured, subscriber, employee, or member;</text> </level> <level label="4"> <text>is the dependent of the insured, subscriber, employee, or member; and</text> </level> <level label="5"> <text>has not attained the limiting age under the terms of the policy or contract.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>An insurer, nonprofit health service plan, or health maintenance organization may require proof that the insured or subscriber is the grandparent of the grandchild.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-403.1" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>each individual health insurance policy that:</text> <level label="i"> <text>provides coverage on an expense–incurred basis; and</text> </level> <level label="ii"> <text>provides coverage for a family member of the insured;</text> </level> </level> <level label="2"> <text>each group health insurance policy that:</text> <level label="i"> <text>provides coverage on an expense–incurred basis for employees of an employer or employers or members of a union or unions; and</text> </level> <level label="ii"> <text>provides coverage for a family member of a covered employee or member;</text> </level> </level> <level label="3"> <text>each individual service or indemnity contract that:</text> <level label="i"> <text>is issued by a nonprofit health service plan; and</text> </level> <level label="ii"> <text>provides coverage for a family member of the subscriber;</text> </level> </level> <level label="4"> <text>each individual contract that:</text> <level label="i"> <text>is issued by a health maintenance organization; and</text> </level> <level label="ii"> <text>provides coverage for a family member of the subscriber; and</text> </level> </level> <level label="5"> <text>each group contract that:</text> <level label="i"> <text>is issued by a health maintenance organization;</text> </level> <level label="ii"> <text>provides coverage for employees of an employer or employers or members of a union or unions; and</text> </level> <level label="iii"> <text>provides coverage for a family member of the covered employee or member.</text> </level> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>is unmarried;</text> </level> <level label="2"> <text>is under testamentary or court appointed guardianship, other than temporary guardianship of less than 12 months duration, of the insured, subscriber, employee, or member;</text> </level> <level label="3"> <text>resides with the insured, subscriber, employee, or member;</text> </level> <level label="4"> <text>is the dependent of the insured, subscriber, employee, or member; and</text> </level> <level label="5"> <text>has not attained the limiting age under the terms of the policy or contract.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-403.2" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <text>In this section, “child dependent of the domestic partner” means an individual who:</text> <level label="1"> <text>is:</text> <level label="i"> <text>the natural child, stepchild, adopted child, or grandchild of the domestic partner of an insured;</text> </level> <level label="ii"> <text>a child placed with the domestic partner of an insured for legal adoption; or</text> </level> <level label="iii"> <text>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;</text> </level> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>resides with the insured;</text> </level> <level label="4"> <text>is unmarried; and</text> </level> <level label="5"> <text>is under the age of 25 years.</text> </level> </level> <level label="b"> <text>This section applies to each individual or group policy or contract that:</text> <level label="1"> <text>allows family coverage; and</text> </level> <level label="2"> <text>is issued by:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>an insured under an individual policy or contract that is subject to this section; or</text> </level> <level label="2"> <text>the group policyholder of a group policy or contract that is subject to this section.</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>The Commissioner shall adopt regulations to implement this section.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-404" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>each group or blanket health insurance policy that is issued or delivered in the State and provides coverage on an expense-incurred basis; and</text> </level> <level label="2"> <text>each group medical or major medical contract or certificate that is issued or delivered in the State by a nonprofit health service plan.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>the dependent children previously were covered under the policy or contract of the certificate holder’s or subscriber’s spouse; and</text> </level> <level label="2"> <text>the certificate holder’s or subscriber’s spouse has died.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>Within 6 months after the death of the spouse, the certificate holder or subscriber must exercise the benefit provided under this section.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-405" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer that holds a certificate of authority in the State and provides health insurance in the State;</text> </level> <level label="ii"> <text>a health maintenance organization that is licensed to operate in the State; or</text> </level> <level label="iii"> <text>a nonprofit health service plan that is licensed to operate in the State.</text> </level> </level> <level label="3"> <text>“Health insurance coverage” means health care coverage under which medical care services can be provided to a child.</text> </level> <level label="4"> <text>“Insuring parent” means a parent who:</text> <level label="i"> <text>is required under a court or administrative order to provide health insurance coverage for a child; or</text> </level> <level label="ii"> <text>otherwise provides health insurance coverage for a child.</text> </level> </level> <level label="5"> <text>“Medical support notice” means a notice that is:</text> <level label="i"> <text>in a format prescribed by federal law; and</text> </level> <level label="ii"> <text>issued by a child support agency to enforce the health insurance coverage provisions of a child support order.</text> </level> </level> <level label="6"> <text>“Order” means a ruling that:</text> <level label="i"> <text>is issued by a court of this State or another state or an administrative agency of another state; and</text> </level> <level label="ii"> <level label="1"> <text>creates or recognizes the right of a child to receive benefits under a parent’s health insurance coverage; or</text> </level> <level label="2"> <text>establishes a parent’s obligation to pay child support and provide health insurance coverage for a child.</text> </level> </level> </level> <level label="7"> <text>“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).</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>insurers, nonprofit health service plans, and health maintenance organizations that operate in the State under a certificate of authority;</text> </level> <level label="2"> <text>group health plans, as defined in § 607(1) of the Employee Retirement Income Security Act of 1974 (ERISA); and</text> </level> <level label="3"> <text>persons that offer a service benefit plan, as defined in federal law.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>shall allow the insuring parent to enroll in family members’ coverage and include the child in that coverage regardless of enrollment period restrictions;</text> </level> <level label="2"> <text>if the insuring parent is enrolled in health insurance coverage but does not include the child in the enrollment, shall:</text> <level label="i"> <text>allow the noninsuring parent, child support enforcement agency, or Maryland Department of Health to apply for enrollment on behalf of the child; and</text> </level> <level label="ii"> <text>include the child in the coverage regardless of enrollment period restrictions; and</text> </level> </level> <level label="3"> <text>may not terminate health insurance coverage for the child unless written evidence is provided to the entity that:</text> <level label="i"> <text>the order is no longer in effect;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>the employer has eliminated family members’ coverage for all of its employees; or</text> </level> <level label="iv"> <text>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.</text> </level> </level> </level> <level label="d"> <text>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:</text> <level label="1"> <text>was born out of wedlock;</text> </level> <level label="2"> <text>is not claimed as a dependent on the insuring parent’s federal income tax return;</text> </level> <level label="3"> <text>does not reside with the insuring parent or in the service area of the entity; or</text> </level> <level label="4"> <text>is receiving benefits or is eligible to receive benefits under the Maryland Medical Assistance Program.</text> </level> </level> <level label="e"> <text>If a child has health insurance coverage through an insuring parent, an entity subject to this section shall:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <text>Within 20 business days after receipt of a medical support notice from an employer, the carrier:</text> <level label="1"> <text>shall determine whether the medical support notice contains:</text> <level label="i"> <text>the employee’s name and mailing address; and</text> </level> <level label="ii"> <text>the child’s name and the child’s mailing address or the address of a substituted official;</text> </level> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>if the medical support notice contains the information described in paragraph (1) of this subsection, shall comply with the following requirements:</text> <level label="i"> <text>determine the child’s eligibility for enrollment;</text> </level> <level label="ii"> <text>complete and send the appropriate part of the medical support notice to the employer and the Child Support Administration;</text> </level> <level label="iii"> <text>enroll the child if the child is eligible for enrollment, subject to subsection (g) of this section;</text> </level> <level label="iv"> <text>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</text> </level> <level label="v"> <text>send to the custodial parent of the child a written description of:</text> <level label="1"> <text>the health insurance coverage;</text> </level> <level label="2"> <text>the effective date of coverage;</text> </level> <level label="3"> <text>the employee’s cost for the health insurance coverage; and</text> </level> <level label="4"> <text>if not already provided:</text> </level> <level label="A"> <text>a summary plan description;</text> </level> <level label="B"> <text>any forms, documents, or information necessary to effectuate coverage; and</text> </level> <level label="C"> <text>any information necessary to submit claims for benefits.</text> </level> </level> </level> </level> <level label="g"> <text>If the employee’s eligibility for health insurance coverage is subject to a waiting period that has not been completed, the carrier:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="h"> <text>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.</text> </level> <level label="i"> <text>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.</text> </level> <level label="j"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-406" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <text>In this section, “health insurance coverage” means health care coverage under which medical care services can be provided to a child.</text> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>commercial insurers, nonprofit health service plans, and health maintenance organizations that operate in the State under a certificate of authority;</text> </level> <level label="2"> <text>group health plans, as defined in § 607(1) of the Employee Retirement Income Security Act of 1974 (ERISA); and</text> </level> <level label="3"> <text>persons that offer a service benefit plan, as defined in federal law.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>determining the eligibility of the individual for enrollment in health insurance coverage; or</text> </level> <level label="2"> <text>calculating any payments for benefits for which the individual is eligible under the health insurance coverage.</text> </level> </level> <level label="d"> <text>On presentation of a claim, an entity subject to this section shall reimburse the State to the extent that:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>those health care services are included under the individual’s health insurance coverage provided by the entity.</text> </level> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-407" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Dependent child” means a child of the insured who:</text> <level label="i"> <text>was covered under a group contract as a qualified or eligible dependent of the insured immediately before the death of the insured; or</text> </level> <level label="ii"> <text>was born to a qualified secondary beneficiary defined in paragraph (5)(i) of this subsection after the death of the insured.</text> </level> </level> <level label="3"> <text>“Group contract” means:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="4"> <text>“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.</text> </level> <level label="5"> <text>“Qualified secondary beneficiary” means an individual who is:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>a dependent child of the insured.</text> </level> </level> </level> <level label="b"> <level label="1"> <text>Each group contract in force on the date of the death of the insured shall provide continuation coverage in accordance with this section.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>18 months after the date of the death of the insured;</text> </level> <level label="2"> <text>the date on which the qualified secondary beneficiary fails to make timely payment of an amount required under subsection (d)(2) of this section;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>the date on which the qualified secondary beneficiary becomes entitled to benefits under Title XVIII of the Social Security Act;</text> </level> <level label="5"> <text>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;</text> </level> <level label="6"> <text>the date on which the qualified secondary beneficiary elects to terminate coverage under the group contract;</text> </level> <level label="7"> <text>the date on which the employer ceases to provide benefits to its employees under a group contract; or</text> </level> <level label="8"> <text>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.</text> </level> </level> <level label="d"> <text>Continuation coverage under this section shall:</text> <level label="1"> <text>be provided without evidence of insurability or additional waiting periods;</text> </level> <level label="2"> <text>require the qualified secondary beneficiary to pay to the employer an amount that does not exceed:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>a reasonable administrative fee that is subject to review and approval by the Commissioner;</text> </level> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>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.</text> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="f"> <text>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:</text> <level label="1"> <text>the availability of continuation coverage under this section;</text> </level> <level label="2"> <text>a summary of the eligibility for and duration of the continuation coverage; and</text> </level> <level label="3"> <text>the procedure for making an election to receive continuation coverage if the insured dies.</text> </level> </level> <level label="g"> <text>The Commissioner shall:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>prescribe by regulation the form and content of the election notification form; and</text> </level> <level label="3"> <text>make election notification forms available to each employer whose employees are covered by a group contract.</text> </level> </level> <level label="h"> <text>Notice of the availability of continuation coverage under this section shall be provided by:</text> <level label="1"> <text>the Secretary of Health as specified in § 4–217 of the Health – General Article; and</text> </level> <level label="2"> <text>licensed funeral directors as specified in § 7–407 of the Health Occupations Article.</text> </level> </level> <level label="i"> <text>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.</text> </level> <level label="j"> <text>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:</text> <level label="1"> <text>is made in good faith;</text> </level> <level label="2"> <text>is reasonable under the circumstances; and</text> </level> <level label="3"> <text>is not the result of a mutual or material mistake of fact.</text> </level> </level> <level label="k"> <text>This section does not affect or limit the right of a qualified secondary beneficiary to conversion privileges under a group contract.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-408" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Change in status” means the divorce of the insured and the insured’s spouse.</text> </level> <level label="3"> <text>“Dependent child” means a child of the insured who:</text> <level label="i"> <text>was covered under a group contract as a qualified or eligible dependent of the insured immediately before the change in status; or</text> </level> <level label="ii"> <text>was born to a qualified secondary beneficiary defined in paragraph (6)(i) of this subsection after the change in status.</text> </level> </level> <level label="4"> <text>“Group contract” means:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="5"> <text>“Insured” means an employee who is a resident of the State and covered under a group contract.</text> </level> <level label="6"> <text>“Qualified secondary beneficiary” means an individual who is:</text> <level label="i"> <text>a beneficiary under the group contract as the spouse of the insured for at least 30 days immediately preceding the change in status; or</text> </level> <level label="ii"> <text>a dependent child of the insured.</text> </level> </level> <level label="7"> <text>“Termination statement” means written notice of an event specified in subsection (c) of this section that is:</text> <level label="i"> <text>provided to the employer on a form that the Commissioner prescribes; and</text> </level> <level label="ii"> <level label="1"> <text>signed by the insured and a qualified secondary beneficiary defined in paragraph (6)(i) of this subsection; or</text> </level> <level label="2"> <text>accompanied by the insured’s signed and sworn affidavit that verifies all facts in the termination statement.</text> </level> </level> </level> </level> <level label="b"> <level label="1"> <text>Each group contract in force on the date of the change in status shall provide continuation coverage in accordance with this section.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>Paragraph (2) of this subsection does not apply while the insured is not covered by a group contract.</text> </level> </level> <level label="c"> <text>Continuation coverage under this section shall begin on the date of the change in status and end on the earliest of the following:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>the date on which the qualified secondary beneficiary becomes entitled to benefits under Title XVIII of the Social Security Act;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>the date on which the qualified secondary beneficiary elects to terminate coverage under the group contract;</text> </level> <level label="5"> <text>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</text> </level> <level label="6"> <text>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.</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <text>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:</text> <level label="1"> <text>the availability of continuation coverage under this section; and</text> </level> <level label="2"> <text>a summary of the eligibility for and duration of the continuation coverage.</text> </level> </level> <level label="g"> <text>The Commissioner shall:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>prescribe by regulation the form and content of the termination statement; and</text> </level> <level label="3"> <text>make termination statement forms available to each employer whose employees are covered by a group contract.</text> </level> </level> <level label="h"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> </level> <level label="i"> <level label="1"> <text>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:</text> <level label="i"> <text>is made in good faith;</text> </level> <level label="ii"> <text>is reasonable under the circumstances; and</text> </level> <level label="iii"> <text>is not the result of a mutual or material mistake of fact.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="j"> <text>This section does not affect or limit the right of a qualified secondary beneficiary to conversion privileges under a group contract.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-409" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“Change in status” means the termination of the insured’s employment other than for cause.</text> </level> <level label="ii"> <text>“Change in status” includes:</text> <level label="1"> <text>involuntary termination of the insured’s employment other than for cause; and</text> </level> <level label="2"> <text>voluntary termination of the insured’s employment by the insured employee.</text> </level> </level> </level> <level label="3"> <text>“Group contract” means:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="4"> <text>“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.</text> </level> </level> <level label="b"> <level label="1"> <text>Each group contract in force on the date of the change in status shall provide continuation coverage in accordance with this section.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>18 months after the date of the change in status;</text> </level> <level label="2"> <text>the date on which the insured fails to make timely payment of an amount required under subsection (d)(2) of this section;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>the date on which the insured becomes entitled to benefits under Title XVIII of the Social Security Act;</text> </level> <level label="5"> <text>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;</text> </level> <level label="6"> <text>the date on which the insured elects to terminate coverage under the group contract; or</text> </level> <level label="7"> <text>the date on which the employer ceases to provide benefits to its employees under a group contract.</text> </level> </level> <level label="d"> <text>Continuation coverage under this section shall:</text> <level label="1"> <text>be provided without evidence of insurability or additional waiting periods;</text> </level> <level label="2"> <text>require the insured to pay to the employer an amount that does not exceed:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>a reasonable administrative fee that is subject to review and approval by the Commissioner;</text> </level> </level> <level label="3"> <text>allow the payment of the amount specified in item (2) of this subsection in monthly installments if the insured elects to do so;</text> </level> <level label="4"> <text>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</text> </level> <level label="5"> <text>be available to the spouse and dependent children of the insured if:</text> <level label="i"> <text>the group contract provides benefits for spouses and dependent children; and</text> </level> <level label="ii"> <text>the insured’s spouse and dependent children were covered under the group contract before the change in status.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="f"> <text>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:</text> <level label="1"> <text>the availability of continuation coverage under this section;</text> </level> <level label="2"> <text>a summary of the eligibility for and duration of the continuation coverage; and</text> </level> <level label="3"> <text>the procedure for making an election to receive continuation coverage if a change in status occurs.</text> </level> </level> <level label="g"> <text>The Commissioner shall:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>prescribe by regulation the form and content of the election notification form; and</text> </level> <level label="3"> <text>make election notification forms available to each employer whose employees are covered by a group contract.</text> </level> </level> <level label="h"> <text>Notice of the availability of continuation coverage under this section shall be provided by:</text> <level label="1"> <text>the employer; and</text> </level> <level label="2"> <text>the Secretary of Labor as specified in § 8–805(c) of the Labor and Employment Article.</text> </level> </level> <level label="i"> <text>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.</text> </level> <level label="j"> <text>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:</text> <level label="1"> <text>is made in good faith;</text> </level> <level label="2"> <text>is reasonable under the circumstances; and</text> </level> <level label="3"> <text>is not the result of a mutual or material mistake of fact.</text> </level> </level> <level label="k"> <text>This section does not affect or limit the right of an insured to conversion privileges under a group contract.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-409.1" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Act” means the federal American Recovery and Reinvestment Act of 2009 (P.L. 111–5).</text> </level> <level label="3"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan; or</text> </level> <level label="iii"> <text>a health maintenance organization.</text> </level> </level> <level label="4"> <text>“Small employer” has the meaning stated in § 15–1201 of this title.</text> </level> </level> <level label="b"> <text>This section applies to a carrier that issues health benefit plans to small employers in accordance with Subtitle 12 of this title.</text> </level> <level label="c"> <text>A carrier shall allow an extended election period for continuation coverage under § 15–409 of this subtitle if the individual:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>was eligible for continuation coverage under § 15–409 of this subtitle at the time of the individual’s termination of employment.</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>Any continuation coverage elected by an individual during an extended election period under this section:</text> <level label="1"> <text>shall begin during the first period of coverage beginning on or after the individual’s election of continuation coverage; and</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-411" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-413" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <level label="1"> <text>Except as provided in paragraph (2) of this subsection, this section applies to each group health insurance policy that:</text> <level label="i"> <level label="1"> <text>is issued or delivered in the State;</text> </level> <level label="2"> <text>is issued to a policyholder that is incorporated or has a main office in the State; or</text> </level> <level label="3"> <text>covers individuals who reside or work in the State; and</text> </level> </level> <level label="ii"> <text>provides benefits in the event of the disability of an individual covered under the policy.</text> </level> </level> <level label="2"> <text>This section does not apply to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>except as the Commissioner provides by regulation, a group policy issued to an employer to cover its employees.</text> </level> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>By regulation the Commissioner may exempt from the requirements of this section certain types of group policies that the Commissioner considers appropriate.</text> </level> <level label="d"> <level label="1"> <text>An individual policy issued under this section shall take effect immediately after the termination of coverage under the group policy if the covered individual:</text> <level label="i"> <text>makes a timely written request for an individual policy; and</text> </level> <level label="ii"> <text>pays the first premium for the individual policy.</text> </level> </level> <level label="2"> <text>By regulation the Commissioner shall establish rules to determine when a written request and payment of the required premium are timely.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The insurer shall reserve the right to change the premium on any policy anniversary subject to approval by the Commissioner.</text> </level> </level> <level label="h"> <text>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.</text> </level> <level label="i"> <text>The insurer may limit the right of conversion to individuals who have been covered under the group policy for at least 1 year.</text> </level> <level label="j"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-416" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>notify the parent of criteria under which a child may remain eligible for coverage as a dependent under the policy or contract; and</text> </level> <level label="2"> <text>provide information regarding:</text> <level label="i"> <text>any other policies that may be available to the child from the entity; and</text> </level> <level label="ii"> <text>the availability of additional information from the Administration regarding individual policies in the State.</text> </level> </level> </level> <level label="c"> <text>The Commissioner shall establish and publish by bulletin the notice to be given under this section.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-417" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>is maintaining a course load of at least 7 credit hours per semester.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-418" title_number="15" title_name="Health Insurance" subtitle_number="4" subtitle_name="Eligibility for Coverage; Continuation and Conversion of Policies"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan; or</text> </level> <level label="iii"> <text>a health maintenance organization.</text> </level> </level> <level label="3"> <text>“Child dependent” means an individual who:</text> <level label="i"> <text>is:</text> <level label="1"> <text>the grandchild of the insured; or</text> </level> <level label="2"> <text>a child who is entitled to dependent coverage under § 15–403.1 of this subtitle;</text> </level> </level> <level label="ii"> <text>is unmarried; and</text> </level> <level label="iii"> <text>is under the age of 25 years.</text> </level> </level> </level> <level label="b"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>each policy of individual or group health insurance that is issued in the State;</text> </level> <level label="ii"> <text>each contract that is issued in the State by a nonprofit health service plan; and</text> </level> <level label="iii"> <text>each contract that is issued in the State by a health maintenance organization.</text> </level> </level> <level label="2"> <text>Notwithstanding paragraph (1) of this subsection, this section does not apply to:</text> <level label="i"> <text>a contract covering one or more, or any combination of the following:</text> <level label="1"> <text>coverage only for loss caused by an accident;</text> </level> <level label="2"> <text>disability coverage;</text> </level> <level label="3"> <text>credit–only insurance; or</text> </level> <level label="4"> <text>long–term care coverage; or</text> </level> </level> <level label="ii"> <text>the following benefits if they are provided under a separate contract:</text> <level label="1"> <text>dental coverage;</text> </level> <level label="2"> <text>vision coverage;</text> </level> <level label="3"> <text>Medicare supplement insurance;</text> </level> <level label="4"> <text>coverage limited to benefits for a specified disease or diseases;</text> </level> <level label="5"> <text>travel accident or sickness coverage; and</text> </level> <level label="6"> <text>fixed indemnity limited benefit insurance that does not provide benefits on an expense incurred basis.</text> </level> </level> </level> </level> <level label="c"> <text>Each policy or contract subject to this section that provides coverage for dependents shall:</text> <level label="1"> <text>include coverage for a child dependent;</text> </level> <level label="2"> <text>provide the same health insurance benefits to a child dependent that are available to any other covered dependent; and</text> </level> <level label="3"> <text>provide health insurance benefits to a child dependent at the same rate or premium applicable to any other covered dependent.</text> </level> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-501" title_number="15" title_name="Health Insurance" subtitle_number="5" subtitle_name="Prohibited Denials, Exclusions, and Reductions of Coverage"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-502" title_number="15" title_name="Health Insurance" subtitle_number="5" subtitle_name="Prohibited Denials, Exclusions, and Reductions of Coverage"> <level label="a"> <text>This section applies to each individual or group policy or certificate of health insurance or automobile insurance that is:</text> <level label="1"> <text>delivered or issued for delivery in the State by an insurer or nonprofit health service plan; and</text> </level> <level label="2"> <text>issued, renewed, amended, or reissued on or after July 1, 1978.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-503" title_number="15" title_name="Health Insurance" subtitle_number="5" subtitle_name="Prohibited Denials, Exclusions, and Reductions of Coverage"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-505" title_number="15" title_name="Health Insurance" subtitle_number="5" subtitle_name="Prohibited Denials, Exclusions, and Reductions of Coverage"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>Coverage extends to individuals confined at home, who are otherwise eligible, regardless of the place of medical treatment.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-506" title_number="15" title_name="Health Insurance" subtitle_number="5" subtitle_name="Prohibited Denials, Exclusions, and Reductions of Coverage"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>all covered employees or members; or</text> </level> <level label="ii"> <text>all covered employees or members and all covered dependents of employees or members.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-508.1" title_number="15" title_name="Health Insurance" subtitle_number="5" subtitle_name="Prohibited Denials, Exclusions, and Reductions of Coverage"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means an insurer or a nonprofit health service plan.</text> </level> <level label="3"> <text>“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.</text> </level> <level label="4"> <text>“Health benefit plan” has the meaning stated in § 15–1301 of this title.</text> </level> <level label="5"> <text>“Individual health benefit plan” means a health benefit plan issued by a carrier that insures:</text> <level label="i"> <text>only one individual; or</text> </level> <level label="ii"> <text>one individual and one or more family members of the individual.</text> </level> </level> </level> <level label="b"> <text>This section applies to individual health benefit plans that are issued or delivered in the State before March 23, 2010.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>extends for a period of not more than 12 months after the effective date of the individual’s coverage.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-509" title_number="15" title_name="Health Insurance" subtitle_number="5" subtitle_name="Prohibited Denials, Exclusions, and Reductions of Coverage"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan; or</text> </level> <level label="iii"> <text>a health maintenance organization.</text> </level> </level> <level label="4"> <text>“Grandfathered health benefit plan” has the meaning stated in § 1251 of the Affordable Care Act.</text> </level> <level label="5"> <text>“Health benefit plan” has the meaning stated in § 15–1301 of this title.</text> </level> <level label="6"> <level label="i"> <text>“Health–contingent wellness program” means a program that requires an individual to satisfy a standard related to a health factor to obtain a reward.</text> </level> <level label="ii"> <text>“Health–contingent wellness program” includes:</text> <level label="1"> <text>an activity–only wellness program; and</text> </level> <level label="2"> <text>an outcome–based wellness program.</text> </level> </level> </level> <level label="7"> <text>“Health factor” means, in relation to an individual, any of the following health status–related factors:</text> <level label="i"> <text>health status;</text> </level> <level label="ii"> <text>medical condition;</text> </level> <level label="iii"> <text>claims experience;</text> </level> <level label="iv"> <text>receipt of health care;</text> </level> <level label="v"> <text>medical history;</text> </level> <level label="vi"> <text>genetic information;</text> </level> <level label="vii"> <text>evidence of insurability;</text> </level> <level label="viii"> <text>disability; or</text> </level> <level label="ix"> <text>any other health status–related factor determined appropriate by the U.S. Secretary of Health and Human Services.</text> </level> </level> <level label="8"> <text>“Incentive” means:</text> <level label="i"> <text>a discount of a premium or contribution;</text> </level> <level label="ii"> <text>a waiver of all or part of a cost–sharing mechanism, such as deductibles, copayments, or coinsurance;</text> </level> <level label="iii"> <text>the absence of a surcharge;</text> </level> <level label="iv"> <text>the value of a benefit that otherwise would not be provided under the policy or contract; or</text> </level> <level label="v"> <text>a rebate as permitted under § 27–210 of this article.</text> </level> </level> <level label="9"> <text>“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.</text> </level> <level label="10"> <text>“Participatory wellness program” means a program that does not:</text> <level label="i"> <text>provide a reward; or</text> </level> <level label="ii"> <text>include any conditions for obtaining a reward that are based on an individual satisfying a standard that is related to a health factor.</text> </level> </level> <level label="11"> <text>“Reward” means:</text> <level label="i"> <text>obtaining an incentive; or</text> </level> <level label="ii"> <text>avoiding a penalty.</text> </level> </level> </level> <level label="b"> <text>This section applies to grandfathered and nongrandfathered individual and group health benefit plans.</text> </level> <level label="c"> <level label="1"> <text>A carrier may include a participatory wellness program as part of an individual or group health benefit plan.</text> </level> <level label="2"> <text>A participatory wellness program shall be made available to all similarly situated individuals regardless of health status.</text> </level> </level> <level label="d"> <text>A carrier may condition a reward for an activity–only wellness program in a group health benefit plan if:</text> <level label="1"> <text>the activity–only wellness program provides individuals with an opportunity to qualify for the reward at least once a year;</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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;</text> </level> </level> <level label="3"> <text>the activity–only wellness program is reasonably designed to promote health or prevent disease;</text> </level> <level label="4"> <text>the full reward under the activity–only wellness program is available to all similarly situated individuals; and</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="e"> <text>An activity–only wellness program shall be construed to be reasonably designed to promote health or prevent disease if the activity–only wellness program:</text> <level label="1"> <text>has a reasonable chance of improving the health of or preventing disease in participating individuals;</text> </level> <level label="2"> <text>is not overly burdensome;</text> </level> <level label="3"> <text>is not a subterfuge for discriminating based on a health factor;</text> </level> <level label="4"> <text>is not highly suspect in the method chosen to promote health or prevent disease; and</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="f"> <level label="1"> <text>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:</text> <level label="i"> <text>unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard; or</text> </level> <level label="ii"> <text>medically inadvisable to attempt to satisfy the otherwise applicable standard.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="g"> <level label="1"> <text>A carrier may condition the reward for an outcome–based wellness program in a group health benefit plan if:</text> <level label="i"> <text>the outcome–based wellness program meets the requirements under subsections (d) and (e) of this section;</text> </level> <level label="ii"> <text>the full reward is available to all similarly situated individuals; and</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="2"> <text>If the reasonable alternative standard is an educational program, the carrier:</text> <level label="i"> <text>shall make the educational program available or assist the individual in finding a program; and</text> </level> <level label="ii"> <text>may not require an individual to pay for the cost of the educational program.</text> </level> </level> <level label="3"> <text>The time commitment required for the alternative standard shall be reasonable.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>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.</text> </level> <level label="6"> <text>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.</text> </level> <level label="7"> <text>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.</text> </level> <level label="8"> <text>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.</text> </level> </level> <level label="h"> <text>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.</text> </level> <level label="i"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-510" title_number="15" title_name="Health Insurance" subtitle_number="5" subtitle_name="Prohibited Denials, Exclusions, and Reductions of Coverage"> <text>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. </text> </section> <section article="gin" article_name="Insurance" number="15-601" title_number="15" title_name="Health Insurance" subtitle_number="6" subtitle_name="Required Reimbursement of Institutions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>excludes the reasonable cost of medical education and of uncompensated care as determined by the Health Services Cost Review Commission;</text> </level> <level label="2"> <text>excludes the cost associated with a shock trauma facility as determined by the Health Services Cost Review Commission;</text> </level> <level label="3"> <text>excludes the amount in rates approved by the Health Services Cost Review Commission for undergraduate nursing education;</text> </level> <level label="4"> <text>excludes from consideration each hospital that is determined by the Maryland Health Care Commission to be a sole community provider; and</text> </level> <level label="5"> <text>compares hospitals on a regional basis, unless the entity demonstrates to the satisfaction of the Commissioner that a statewide comparison is more appropriate.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-602" title_number="15" title_name="Health Insurance" subtitle_number="6" subtitle_name="Required Reimbursement of Institutions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-603" title_number="15" title_name="Health Insurance" subtitle_number="6" subtitle_name="Required Reimbursement of Institutions"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-604" title_number="15" title_name="Health Insurance" subtitle_number="6" subtitle_name="Required Reimbursement of Institutions"> <text>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:</text> <level label="1"> <text>pay hospitals for hospital services rendered on the basis of the rate approved by the Health Services Cost Review Commission; and</text> </level> <level label="2"> <text>comply with the applicable terms and conditions of the all–payer model contract, as defined in § 19–201 of the Health – General Article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-605" title_number="15" title_name="Health Insurance" subtitle_number="6" subtitle_name="Required Reimbursement of Institutions"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The annual report required under this subsection shall:</text> <level label="i"> <text>be submitted in a form required by the Commissioner; and</text> </level> <level label="ii"> <text>include for the preceding calendar year the following data for all health benefit plans specific to the State:</text> <level label="1"> <text>premiums written;</text> </level> <level label="2"> <text>premiums earned;</text> </level> <level label="3"> <text>total amount of incurred claims including reserves for claims incurred but not reported at the end of the previous year;</text> </level> <level label="4"> <text>total amount of incurred expenses, including commissions, acquisition costs, general expenses, taxes, licenses, and fees, estimated if necessary;</text> </level> <level label="5"> <text>loss ratio; and</text> </level> <level label="6"> <text>expense ratio.</text> </level> </level> </level> <level label="3"> <text>The data required under paragraph (2) of this subsection shall be reported in the aggregate.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>The Commissioner may conduct an examination to ensure that an annual report submitted under this subsection is accurate.</text> </level> </level> <level label="b"> <level label="1"> <text>Before a managed care organization may enroll a medical assistance program recipient, the managed care organization shall provide a business plan to the Commissioner.</text> </level> <level label="2"> <text>As part of the annual report required under subsection (a) of this section, a managed care organization shall:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="c"> <level label="1"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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).</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>does not limit any existing authority of the Commissioner to determine whether a rate is excessive.</text> </level> </level> <level label="3"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="4"> <text>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%.</text> </level> <level label="5"> <text>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.</text> </level> <level label="6"> <text>Any rebate received by a managed care organization may not be considered part of the loss ratio of the managed care organization.</text> </level> <level label="7"> <text>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:</text> <level label="i"> <text>appeal the decision of the Secretary to the Board of Review established under Title 2, Subtitle 2 of the Health – General Article; and</text> </level> <level label="ii"> <text>take any further appeal allowed by the Administrative Procedure Act under Title 10, Subtitle 2 of the State Government Article.</text> </level> </level> <level label="8"> <text>The Secretary of Health shall publish in a conspicuous manner on the Web site of the Maryland Department of Health:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>At any time, the Commissioner may require a managed care organization to file an interim statement containing the information that the Commissioner considers necessary.</text> </level> <level label="iii"> <text>The annual and interim reports shall be filed in a form required by the Commissioner.</text> </level> </level> <level label="2"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>The audited financial report shall:</text> <level label="1"> <text>be filed in a form required by the Commissioner; and</text> </level> <level label="2"> <text>be certified by an audit of an independent certified public accountant.</text> </level> </level> </level> <level label="3"> <text>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.</text> </level> </level> <level label="f"> <text>Each financial report filed under this section is a public record.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-701" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <level label="1"> <text>This subsection applies to each individual or group health insurance policy, contract, or certificate that is:</text> <level label="i"> <text>delivered or issued for delivery in the State by an insurer or nonprofit health service plan; and</text> </level> <level label="ii"> <text>issued, renewed, amended, or reissued on or after July 1, 1984.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-702" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>This section applies to each self-funded group insurance plan that:</text> <level label="1"> <level label="i"> <text>is formed by an order, society, or association that is incorporated or has a main office in the State; or</text> </level> <level label="ii"> <text>covers individuals who reside or work in the State; and</text> </level> </level> <level label="2"> <text>is issued, renewed, amended, or reissued on or after July 1, 1972.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-703" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>In this section, “certified nurse practitioner” means a licensed registered nurse who has:</text> <level label="1"> <text>completed a nurse practitioner program approved by the State Board of Nursing; and</text> </level> <level label="2"> <text>passed an examination approved by the State Board of Nursing.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-704" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>This section applies to each individual, group, or blanket health insurance policy, contract, or certificate of an insurer or nonprofit health service plan that:</text> <level label="1"> <level label="i"> <text>is delivered or issued for delivery in the State;</text> </level> <level label="ii"> <text>is issued to a group that is incorporated or has a main office in the State; or</text> </level> <level label="iii"> <text>covers individuals who reside or work in the State; and</text> </level> </level> <level label="2"> <text>is issued, renewed, amended, or reissued on or after October 1, 2003.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-705" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-706" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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:</text> <level label="1"> <text>the usual, customary, and reasonable charges of the dietitian or nutritionist shall be included in the patient’s hospital charges; and</text> </level> <level label="2"> <text>the dietitian or nutritionist may not bill the patient separately for the service.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-707" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>This section applies to each individual, group, or blanket health insurance policy of an insurer or nonprofit health service plan that:</text> <level label="1"> <level label="i"> <text>is delivered or issued for delivery in the State;</text> </level> <level label="ii"> <text>is issued to a group that is incorporated or has a main office in the State; or</text> </level> <level label="iii"> <text>covers individuals who reside or work in the State; and</text> </level> </level> <level label="2"> <text>is issued, renewed, amended, or reissued on or after January 1, 1978.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-708" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>In this section, “nurse anesthetist” means a registered nurse who is certified as a nurse anesthetist by:</text> <level label="1"> <text>the Council on Certification of Nurse Anesthetists; or</text> </level> <level label="2"> <text>the Council on Recertification of Nurse Anesthetists.</text> </level> </level> <level label="b"> <text>This section applies to each individual, group, or blanket health insurance policy, contract, or certificate of an insurer or nonprofit health service plan that:</text> <level label="1"> <level label="i"> <text>is issued or delivered in the State;</text> </level> <level label="ii"> <text>is issued to a group that is incorporated or has a main office in the State; or</text> </level> <level label="iii"> <text>covers individuals who reside or work in the State;</text> </level> </level> <level label="2"> <text>is issued, renewed, amended, or reissued on or after July 1, 1984; and</text> </level> <level label="3"> <text>if issued by an insurer, is written on an expense-incurred basis.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-709" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>In this section, “nurse midwife” means a licensed registered nurse who is certified as a nurse midwife by the American College of Nurse-Midwives.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>This subsection applies to each individual, group, or blanket health insurance policy, contract, or certificate of an insurer or nonprofit health service plan that:</text> <level label="i"> <level label="1"> <text>is issued or delivered in the State;</text> </level> <level label="2"> <text>is issued to a group that is incorporated or has a main office in the State; or</text> </level> <level label="3"> <text>covers individuals who reside or work in the State;</text> </level> </level> <level label="ii"> <text>is issued, renewed, amended, or reissued on or after July 1, 1979; and</text> </level> <level label="iii"> <text>if issued by an insurer, is written on an expense-incurred basis.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-710" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>This section applies to each individual or group health insurance policy or certificate of an insurer that:</text> <level label="1"> <text>is issued or delivered in the State;</text> </level> <level label="2"> <text>is issued to a group that is incorporated or has a main office in the State; or</text> </level> <level label="3"> <text>covers individuals who reside or work in the State.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-711" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>This section applies to each individual or group health insurance policy or contract that is:</text> <level label="1"> <text>delivered or issued for delivery in the State by an insurer or nonprofit health service plan; and</text> </level> <level label="2"> <text>issued, renewed, amended, or reissued on or after October 1, 1993.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-712" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-713" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-714" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>This section applies to each individual or group health insurance policy, contract, or certificate that:</text> <level label="1"> <level label="i"> <text>is issued or delivered in the State;</text> </level> <level label="ii"> <text>is issued to a group that is incorporated or has a main office in the State; or</text> </level> <level label="iii"> <text>covers individuals who reside or work in the State; and</text> </level> </level> <level label="2"> <text>is issued, renewed, amended, or reissued on or after July 1, 1972.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-715" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-716" title_number="15" title_name="Health Insurance" subtitle_number="7" subtitle_name="Required Reimbursement for Services of Health Care Providers"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>Reimbursement for services provided under this section may not be conditioned on whether the licensed pharmacist is:</text> <level label="1"> <text>employed by a physician, pharmacy, or facility; or</text> </level> <level label="2"> <text>acting under a physician’s orders.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-801" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-802" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Alcohol misuse” has the meaning stated in § 8–101 of the Health – General Article.</text> </level> <level label="3"> <text>“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.</text> </level> <level label="4"> <text>“Drug misuse” has the meaning stated in § 8–101 of the Health – General Article.</text> </level> <level label="5"> <text>“Grandfathered health plan coverage” has the meaning stated in 45 C.F.R. § 147.140.</text> </level> <level label="6"> <text>“Health benefit plan” means:</text> <level label="i"> <text>for a group or blanket plan, a health benefit plan as defined in § 15–1401 of this title;</text> </level> <level label="ii"> <text>for an individual plan, a health benefit plan as defined in § 15–1301(l) of this title; or</text> </level> <level label="iii"> <text>short–term limited duration insurance as defined in § 15–1301(s) of this title.</text> </level> </level> <level label="7"> <text>“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.</text> </level> <level label="8"> <text>“Partial hospitalization” means the provision of medically directed intensive or intermediate short–term treatment:</text> <level label="i"> <text>to an insured, subscriber, or member;</text> </level> <level label="ii"> <text>in a licensed or certified facility or program;</text> </level> <level label="iii"> <text>for mental illness, emotional disorders, drug misuse, or alcohol misuse; and</text> </level> <level label="iv"> <text>for a period of less than 24 hours but more than 4 hours in a day.</text> </level> </level> <level label="9"> <text>“Small employer” has the meaning stated in § 31–101 of this article.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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:</text> <level label="1"> <text>inpatient benefits for services provided in a licensed or certified facility, including hospital inpatient and residential treatment center benefits;</text> </level> <level label="2"> <text>partial hospitalization benefits; and</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <text>the mental illness, emotional disorder, drug misuse, or alcohol misuse is treatable; and</text> </level> <level label="ii"> <text>the treatment is medically necessary.</text> </level> </level> <level label="2"> <text>The benefits required under this section:</text> <level label="i"> <text>shall be provided as one set of benefits covering mental illnesses, emotional disorders, drug misuse, and alcohol misuse;</text> </level> <level label="ii"> <text>shall comply with 45 C.F.R. § 146.136(a) through (d) and 29 C.F.R. § 2590.712(a) through (d);</text> </level> <level label="iii"> <text>subject to paragraph (3) of this subsection, may be delivered under a managed care system; and</text> </level> <level label="iv"> <text>for partial hospitalization under subsection (c)(2) of this section, may not be less than 60 days.</text> </level> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="e"> <text>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:</text> <level label="1"> <text>notice about the benefits required under this section and the federal Mental Health Parity and Addiction Equity Act; and</text> </level> <level label="2"> <text>notice that the insured or member may contact the Administration for further information about the benefits.</text> </level> </level> <level label="f"> <text>An entity that issues or delivers a health benefit plan subject to this section shall:</text> <level label="1"> <text>post a release of information authorization form on its website; and</text> </level> <level label="2"> <text>provide a release of information authorization form by standard mail within 10 business days after a request for the form is received.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-803" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>This section does not apply to whole blood or concentrated red blood cells.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-804" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Medical literature” means scientific studies published in a peer–reviewed national professional medical journal.</text> </level> <level label="3"> <text>“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.</text> </level> <level label="4"> <text>“Standard reference compendia” means any authoritative compendia as recognized periodically by the federal Secretary of Health and Human Services or the Commissioner.</text> </level> </level> <level label="b"> <text>This section does not:</text> <level label="1"> <text>alter any law that limits the coverage of drugs that have not been approved by the federal Food and Drug Administration;</text> </level> <level label="2"> <text>require coverage of a drug if the federal Food and Drug Administration has determined use of the drug to be contraindicated; or</text> </level> <level label="3"> <text>require coverage of experimental drugs not approved for any indication by the federal Food and Drug Administration.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>Coverage of a drug required by this subsection also includes medically necessary services associated with the administration of the drug.</text> </level> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-805" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Authorized prescriber” means a licensed dentist, licensed physician, or licensed podiatrist who is authorized under the Health Occupations Article to prescribe a pharmaceutical product.</text> </level> <level label="3"> <text>“Pharmaceutical product” means a drug or medicine that may be prescribed by an authorized prescriber.</text> </level> </level> <level label="b"> <text>This section does not apply to a policy or contract that is issued to an employer under a collective bargaining agreement.</text> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-806" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-807" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“Inherited metabolic disease” means a disease caused by an inherited abnormality of body chemistry.</text> </level> <level label="ii"> <text>“Inherited metabolic disease” includes a disease for which the State screens newborn babies.</text> </level> </level> <level label="3"> <level label="i"> <text>“Low protein modified food product” means a food product that is:</text> <level label="1"> <text>specially formulated to have less than 1 gram of protein per serving; and</text> </level> <level label="2"> <text>intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease.</text> </level> </level> <level label="ii"> <text>“Low protein modified food product” does not include a natural food that is naturally low in protein.</text> </level> </level> <level label="4"> <text>“Medical food” means a food that is:</text> <level label="i"> <text>intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation; and</text> </level> <level label="ii"> <text>formulated to be consumed or administered enterally under the direction of a physician.</text> </level> </level> </level> <level label="b"> <text>This section applies to each individual hospital or major medical insurance policy, group or blanket health insurance policy, and nonprofit health service plan that:</text> <level label="1"> <text>is delivered or issued for delivery in the State;</text> </level> <level label="2"> <text>is written on an expense-incurred basis; and</text> </level> <level label="3"> <text>provides coverage for a family member of the insured.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>prescribed as medically necessary for the therapeutic treatment of inherited metabolic diseases; and</text> </level> <level label="2"> <text>administered under the direction of a physician.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-808" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “home health care” means the continued care and treatment of a covered individual if:</text> <level label="1"> <text>institutionalization of the individual would have been required if home health care was not provided; and</text> </level> <level label="2"> <text>the individual’s physician establishes and approves in writing the plan of treatment covering the home health care service.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>Home health care shall be provided by:</text> <level label="1"> <text>a hospital that has a valid operating certificate and is certified to provide home health care services; or</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>In determining the benefits for home health care available to a covered individual:</text> <level label="i"> <text>each visit by a member of a home health care team is considered one home health care visit; and</text> </level> <level label="ii"> <text>up to 4 hours of home health care service is considered one home health care visit.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-809" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>Each nonprofit health service plan shall offer benefits for hospice care services to its subscribers.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-810" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>that the patient’s spouse’s sperm be used in the covered treatments or procedures; or</text> </level> <level label="2"> <text>that the patient demonstrate infertility exclusively by means of a history of unsuccessful heterosexual intercourse.</text> </level> </level> <level label="c"> <level label="1"> <text>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:</text> <level label="i"> <text>that are issued or delivered to a small employer in the State; and</text> </level> <level label="ii"> <text>for which the Administration has determined that in vitro fertilization procedures are not essential health benefits, as determined under § 31–116 of this article.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>The benefits under this subsection shall be provided:</text> <level label="i"> <text>for insurers and nonprofit health service plans, to the same extent as the benefits provided for other pregnancy–related procedures; and</text> </level> <level label="ii"> <text>for health maintenance organizations, to the same extent as the benefits provided for other infertility services.</text> </level> </level> </level> <level label="d"> <text>Subsection (c) of this section applies if:</text> <level label="1"> <text>the patient is the policyholder or subscriber or a covered dependent of the policyholder or subscriber;</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the patient’s spouse is unable to produce and deliver functional sperm; and</text> </level> <level label="ii"> <text>the inability to produce and deliver functional sperm does not result from:</text> <level label="1"> <text>a vasectomy; or</text> </level> <level label="2"> <text>another method of voluntary sterilization;</text> </level> </level> </level> <level label="3"> <level label="i"> <text>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:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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</text> </level> </level> <level label="ii"> <text>the infertility of the patient or the patient’s spouse is associated with any of the following medical conditions:</text> <level label="1"> <text>endometriosis;</text> </level> <level label="2"> <text>exposure in utero to diethylstilbestrol, commonly known as DES;</text> </level> <level label="3"> <text>blockage of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy); or</text> </level> <level label="4"> <text>abnormal male factors, including oligospermia, contributing to the infertility;</text> </level> </level> </level> <level label="4"> <text>for an unmarried patient:</text> <level label="i"> <text>the patient has had three attempts of artificial insemination over the course of 1 year failing to result in pregnancy; or</text> </level> <level label="ii"> <text>the infertility is associated with any of the following medical conditions of the patient:</text> <level label="1"> <text>endometriosis;</text> </level> <level label="2"> <text>exposure in utero to diethylstilbestrol, commonly known as DES;</text> </level> <level label="3"> <text>blockage of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy); or</text> </level> <level label="4"> <text>abnormal male factors, including oligospermia, contributing to the infertility;</text> </level> </level> </level> <level label="5"> <text>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</text> </level> <level label="6"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <text>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.</text> </level> <level label="i"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-810.1" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“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.</text> </level> <level label="4"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Standard fertility preservation procedures” includes sperm and oocyte cryopreservation and evaluations, laboratory assessments, medications, and treatments associated with sperm and oocyte cryopreservation.</text> </level> <level label="iii"> <text>“Standard fertility preservation procedures” does not include the storage of sperm or oocytes.</text> </level> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>Except as provided in subsection (d) of this section, an entity subject to this section shall provide coverage for standard fertility preservation procedures:</text> <level label="1"> <text>performed on a policyholder or subscriber or on the covered dependent of a policyholder or subscriber; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-811" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-812" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Attending provider” means an obstetrician, pediatrician, other physician, certified nurse midwife, or pediatric nurse practitioner attending a mother or newborn child.</text> </level> <level label="3"> <text>“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.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide inpatient hospitalization coverage to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>48 hours of inpatient hospitalization care after an uncomplicated vaginal delivery; and</text> </level> <level label="2"> <text>96 hours of inpatient hospitalization care after an uncomplicated cesarean section.</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>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:</text> <level label="i"> <text>one home visit scheduled to occur within 24 hours after hospital discharge; and</text> </level> <level label="ii"> <text>an additional home visit if prescribed by the attending provider.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>A home visit under paragraph (1) or (2) of this subsection shall:</text> <level label="i"> <text>be provided in accordance with generally accepted standards of nursing practice for home care of a mother and newborn child;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>include any services required by the attending provider.</text> </level> </level> </level> <level label="f"> <text>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:</text> <level label="1"> <text>advocating the interest of a mother and newborn child through the entity’s utilization review or appeals system;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>prescribing a home visit under subsection (e)(1)(ii) or (2) of this section.</text> </level> </level> <level label="g"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="h"> <text>An entity subject to this section shall provide notice annually to insureds and enrollees about the coverage provided by this section.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-813" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to each group or blanket health insurance policy that:</text> <level label="1"> <text>is issued or delivered in the State;</text> </level> <level label="2"> <text>is issued or delivered to an entity that is incorporated or has a main office in the State; or</text> </level> <level label="3"> <text>covers individuals who reside or work in the State.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-814" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>An entity subject to this section may not impose a deductible on the coverage required under this section.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-814.1" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“Diagnostic breast examination” means a medically necessary and appropriate examination of the breast that is used to evaluate an abnormality that is:</text> <level label="1"> <text>seen or suspected from a prior screening examination for breast cancer; or</text> </level> <level label="2"> <text>detected by another means of prior examination.</text> </level> </level> <level label="ii"> <text>“Diagnostic breast examination” includes an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound.</text> </level> </level> <level label="3"> <level label="i"> <text>“Supplemental breast examination” means a medically necessary examination of the breast that is used to screen for breast cancer when:</text> <level label="1"> <text>there is no abnormality seen or suspected from a prior examination; and</text> </level> <level label="2"> <text>there is a personal or family medical history or additional factors that may increase an individual’s risk of breast cancer.</text> </level> </level> <level label="ii"> <text>“Supplemental breast examination” includes an examination using breast magnetic resonance imaging, breast ultrasound, or image–guided breast biopsy.</text> </level> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-815" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Mastectomy” means the surgical removal of all or part of a breast.</text> </level> <level label="3"> <level label="i"> <text>“Reconstructive breast surgery” means surgery performed as a result of a mastectomy to reestablish symmetry between the two breasts.</text> </level> <level label="ii"> <text>“Reconstructive breast surgery” includes augmentation mammoplasty, reduction mammoplasty, and mastopexy.</text> </level> </level> </level> <level label="b"> <text>This section applies to contracts issued by:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide medical and surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>A contract subject to this section shall provide coverage for:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>physical complications of all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending physician and the patient.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-816" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>An entity subject to this section:</text> <level label="1"> <text>shall classify an obstetrician/gynecologist as a primary care provider; or</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the care is medically necessary, including care that is routine;</text> </level> <level label="ii"> <text>after each visit for gynecological care, the obstetrician/gynecologist communicates with the woman’s primary care provider about any diagnosis or treatment rendered; and</text> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-817" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “child wellness services” means preventive activities designed to protect children from morbidity and mortality and promote child development.</text> </level> <level label="b"> <text>This section applies to each individual hospital or major medical insurance policy, group or blanket health insurance policy, and nonprofit health service plan that:</text> <level label="1"> <text>is delivered or issued for delivery in the State;</text> </level> <level label="2"> <text>is written on an expense–incurred basis; and</text> </level> <level label="3"> <text>provides coverage for a family member of the insured.</text> </level> </level> <level label="c"> <level label="1"> <text>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:</text> <level label="i"> <text>public health policy;</text> </level> <level label="ii"> <text>professional standards; and</text> </level> <level label="iii"> <text>scientific evidence of effectiveness.</text> </level> </level> <level label="2"> <text>The minimum package of child wellness services shall cover at least:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>universal hearing screening of newborns provided by a hospital before discharge;</text> </level> <level label="iv"> <text>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;</text> </level> <level label="v"> <text>all visits for obesity evaluation and management;</text> </level> <level label="vi"> <text>all visits for and costs of developmental screening as recommended by the American Academy of Pediatrics;</text> </level> <level label="vii"> <text>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</text> </level> <level label="viii"> <text>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.</text> </level> </level> </level> <level label="d"> <text>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:</text> <level label="1"> <text>encourage and help the insured to choose and contact a primary care provider for the expected newborn before delivery; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <level label="1"> <text>A policy or plan subject to this section may not impose a deductible on the coverage required under this section.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="g"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-818" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-819" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>each individual, group, or blanket health insurance policy that is issued or delivered in the State by an insurer; and</text> </level> <level label="2"> <text>each contract or certificate that is issued or delivered in the State by a nonprofit health service plan.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>an objective second opinion given to the insured when required by a utilization review program under § 19-319 of the Health - General Article.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-820" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “orthopedic brace” means a rigid or semi–rigid device that is used to:</text> <level label="1"> <text>support a weak or deformed body member; or</text> </level> <level label="2"> <text>restrict or eliminate motion in a diseased or injured part of the body.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-821" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>This subsection does not apply to intraoral prosthetic devices.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-822" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>insulin–using diabetes;</text> </level> <level label="2"> <text>noninsulin–using diabetes;</text> </level> <level label="3"> <text>elevated or impaired blood glucose levels induced by pregnancy; or</text> </level> <level label="4"> <text>consistent with the American Diabetes Association’s standards, elevated or impaired blood glucose levels induced by prediabetes.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-822.1" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>require a covered individual to pay an amount that is more than the payment amount limit under subsection (b) of this section.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-823" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Qualified individual” means:</text> <level label="i"> <text>an estrogen deficient individual at clinical risk for osteoporosis;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>an individual receiving long–term glucocorticoid (steroid) therapy;</text> </level> <level label="iv"> <text>an individual with primary hyperparathyroidism; or</text> </level> <level label="v"> <text>an individual being monitored to assess the response to or efficacy of an approved osteoporosis drug therapy.</text> </level> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>each individual or group contract of a health maintenance organization that is issued or delivered in the State.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-824" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Authorized prescriber” has the meaning stated in § 12-101 of the Health Occupations Article.</text> </level> <level label="3"> <text>“Maintenance drug” means a drug anticipated to be required for 6 months or more to treat a chronic condition.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>This section does not apply to an insured or enrollee who is a resident of a nursing home.</text> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-825" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>for men who are between 40 and 75 years of age;</text> </level> <level label="2"> <text>when used for the purpose of guiding patient management in monitoring the response to prostate cancer treatment;</text> </level> <level label="3"> <text>when used for staging in determining the need for a bone scan in patients with prostate cancer; or</text> </level> <level label="4"> <text>when used for male patients who are at high risk for prostate cancer.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-826" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide coverage for prescription drugs under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>An entity subject to this section:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>shall provide coverage for the insertion or removal, and any medically necessary examination associated with the use, of such contraceptive drug or device; and</text> </level> <level label="3"> <text>may not impose a different copayment or coinsurance for a contraceptive drug or device than is imposed for any other prescription.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>A religious organization that obtains an exclusion under paragraph (1) of this subsection shall provide its employees reasonable and timely notice of the exclusion.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-826.1" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “authorized prescriber” has the meaning stated in § 12–101 of the Health Occupations Article.</text> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide coverage for contraceptive drugs and devices under individual or group contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>An entity subject to this section:</text> <level label="i"> <text>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:</text> <level label="1"> <level label="A"> <text>an intrauterine device; or</text> </level> </level> <level label="B"> <text>an implantable rod;</text> </level> <level label="2"> <text>approved by the U.S. Food and Drug Administration; and</text> </level> <level label="3"> <text>obtained under a prescription written by an authorized prescriber; and</text> </level> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>approved by the U.S. Food and Drug Administration; and</text> </level> <level label="2"> <text>obtained under a prescription written by an authorized prescriber.</text> </level> </level> </level> <level label="3"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>This subsection may not be construed to require a provider to prescribe, furnish, or dispense 12 months of contraceptives at one time.</text> </level> </level> <level label="e"> <level label="1"> <text>Subject to paragraph (2) of this subsection, an entity subject to this section:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>An entity subject to this section:</text> <level label="i"> <text>may only be required to provide point–of–sale coverage under paragraph (1)(i) of this subsection at in–network pharmacies; and</text> </level> <level label="ii"> <text>may limit the frequency with which the coverage required under paragraph (1)(i) of this subsection is provided.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-826.2" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>This subsection applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="3"> <text>This subsection does not apply to an organization that requests and receives an exclusion from coverage under § 15–826(c) of this subtitle.</text> </level> <level label="4"> <text>An entity subject to this subsection shall provide coverage for male sterilization.</text> </level> </level> <level label="b"> <level label="1"> <text>This subsection applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide coverage for male sterilization under individual or group contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-826.3" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “fertility awareness–based methods” means methods of identifying times of fertility and infertility by an individual to avoid pregnancy, including:</text> <level label="1"> <text>cervical mucus methods;</text> </level> <level label="2"> <text>sympto–thermal or sympto–hormonal methods;</text> </level> <level label="3"> <text>the standard days method; and</text> </level> <level label="4"> <text>the lactational amenorrhea method.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>An entity subject to this section shall provide coverage for instruction by a licensed health care provider on fertility awareness–based methods.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-827" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Cooperative group” includes:</text> <level label="1"> <text>the National Cancer Institute Clinical Cooperative Group;</text> </level> <level label="2"> <text>the National Cancer Institute Community Clinical Oncology Program;</text> </level> <level label="3"> <text>the AIDS Clinical Trials Group; and</text> </level> <level label="4"> <text>the Community Programs for Clinical Research in AIDS.</text> </level> </level> </level> <level label="3"> <text>“FDA” means the federal Food and Drug Administration.</text> </level> <level label="4"> <text>“Member” means a policyholder, subscriber, insured, or certificate holder or a covered dependent of a policyholder, subscriber, insured, or certificate holder.</text> </level> <level label="5"> <text>“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.</text> </level> <level label="6"> <text>“NIH” means the National Institutes of Health.</text> </level> <level label="7"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Patient cost” does not include:</text> <level label="1"> <text>the cost of an investigational drug or device;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>costs associated with managing the research associated with the clinical trial; or</text> </level> <level label="4"> <text>costs that would not be covered under the patient’s policy, plan, or contract for noninvestigational treatments.</text> </level> </level> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>This section does not apply to a policy, plan, or contract paid for under Title XVIII or Title XIX of the Social Security Act.</text> </level> <level label="d"> <text>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:</text> <level label="1"> <text>treatment provided for a life-threatening condition; or</text> </level> <level label="2"> <text>prevention, early detection, and treatment studies on cancer.</text> </level> </level> <level label="e"> <text>The coverage under subsection (d) of this section shall be required if:</text> <level label="1"> <level label="i"> <text>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</text> </level> <level label="ii"> <text>the treatment is being provided in a Phase I, Phase II, Phase III, or Phase IV clinical trial for any other life-threatening condition;</text> </level> </level> <level label="2"> <text>the treatment is being provided in a clinical trial approved by:</text> <level label="i"> <text>one of the National Institutes of Health;</text> </level> <level label="ii"> <text>an NIH cooperative group or an NIH center;</text> </level> <level label="iii"> <text>the FDA in the form of an investigational new drug application;</text> </level> <level label="iv"> <text>the federal Department of Veterans Affairs; or</text> </level> <level label="v"> <text>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;</text> </level> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>there is no clearly superior, noninvestigational treatment alternative; and</text> </level> <level label="5"> <text>the available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as the noninvestigational alternative.</text> </level> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The list shall include, for each clinical trial:</text> <level label="i"> <text>the phase for which the trial is approved;</text> </level> <level label="ii"> <text>the entity approving the trial;</text> </level> <level label="iii"> <text>whether the trial is for treatment of cancer or another life-threatening disease and, if not cancer, the particular disease; and</text> </level> <level label="iv"> <text>the estimated number of participants in the trial.</text> </level> </level> </level> <level label="h"> <text>This section may not be construed to affect compliance with § 15-804 of this subtitle regarding coverage for off-label use of drugs.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-828" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <level label="i"> <text>is 7 years of age or younger or is developmentally disabled;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>is an individual for whom a superior result can be expected from dental care provided under general anesthesia; or</text> </level> </level> <level label="2"> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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:</text> <level label="1"> <text>a fully accredited specialist in pediatric dentistry;</text> </level> <level label="2"> <text>a fully accredited specialist in oral and maxillofacial surgery; and</text> </level> <level label="3"> <text>a dentist to whom hospital privileges have been granted.</text> </level> </level> <level label="e"> <text>The provisions of this section may not be construed to require coverage for the dental care for which the general anesthesia is provided.</text> </level> <level label="f"> <text>The provisions of this section do not apply to dental care rendered for temporal mandibular joint disorders.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-829" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Chlamydia screening test” means any laboratory test that:</text> <level label="i"> <text>specifically detects for infection by one or more agents of chlamydia trachomatis; and</text> </level> <level label="ii"> <text>is approved for this purpose by the federal Food and Drug Administration.</text> </level> </level> <level label="3"> <text>“Human papillomavirus screening test” means any laboratory test that:</text> <level label="i"> <text>specifically detects for infection by one or more agents of the human papillomavirus; and</text> </level> <level label="ii"> <text>is approved for this purpose by the federal Food and Drug Administration.</text> </level> </level> <level label="4"> <text>“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.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>An entity subject to this section shall:</text> <level label="1"> <text>provide coverage for an annual routine chlamydia screening test for:</text> <level label="i"> <text>women who are:</text> <level label="1"> <text>under the age of 20 years if they are sexually active; and</text> </level> <level label="2"> <text>at least 20 years old if they have multiple risk factors; and</text> </level> </level> <level label="ii"> <text>men who have multiple risk factors; and</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-830" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer that offers health insurance other than long–term care insurance or disability insurance;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization; or</text> </level> <level label="v"> <text>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.</text> </level> </level> <level label="3"> <level label="i"> <text>“Member” means an individual entitled to health care benefits under a policy or plan issued or delivered in the State by a carrier.</text> </level> <level label="ii"> <text>“Member” includes a subscriber.</text> </level> </level> <level label="4"> <text>“Nonphysician specialist” means a health care provider:</text> <level label="i"> <level label="1"> <text>who is not a physician;</text> </level> <level label="2"> <text>who is licensed or certified under the Health Occupations Article; and</text> </level> <level label="3"> <text>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</text> </level> </level> <level label="ii"> <text>that is licensed as a behavioral health program under § 7.5–401 of the Health – General Article.</text> </level> </level> <level label="5"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“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.</text> </level> </level> <level label="6"> <text>“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.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The procedure shall provide for a standing referral to a specialist if:</text> <level label="i"> <text>the primary care physician of the member determines, in consultation with the specialist, that the member needs continuing care from the specialist;</text> </level> <level label="ii"> <text>the member has a condition or disease that:</text> <level label="1"> <text>is life threatening, degenerative, chronic, or disabling; and</text> </level> <level label="2"> <text>requires specialized medical care; and</text> </level> </level> <level label="iii"> <text>the specialist:</text> <level label="1"> <text>has expertise in treating the life–threatening, degenerative, chronic, or disabling disease or condition; and</text> </level> <level label="2"> <text>is part of the carrier’s provider panel.</text> </level> </level> </level> <level label="3"> <text>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:</text> <level label="i"> <text>the primary care physician;</text> </level> <level label="ii"> <text>the specialist; and</text> </level> <level label="iii"> <text>the member.</text> </level> </level> <level label="4"> <text>A treatment plan may:</text> <level label="i"> <text>limit the number of visits to the specialist;</text> </level> <level label="ii"> <text>limit the period of time in which visits to the specialist are authorized; and</text> </level> <level label="iii"> <text>require the specialist to communicate regularly with the primary care physician regarding the treatment and health status of the member.</text> </level> </level> <level label="5"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>A written treatment plan may not be required when a standing referral is to an obstetrician under this subsection.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The procedure shall provide for a referral to a specialist or nonphysician specialist who is not part of the carrier’s provider panel if:</text> <level label="i"> <level label="1"> <text>the member is diagnosed with a condition or disease that requires specialized health care services or medical care; and</text> </level> <level label="2"> <level label="A"> <text>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</text> </level> </level> <level label="B"> <text>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</text> </level> </level> <level label="ii"> <level label="1"> <text>the member is seeking mental health or substance use disorder care; and</text> </level> <level label="2"> <text>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.</text> </level> </level> </level> <level label="3"> <text>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:</text> <level label="i"> <text>appropriate for the member’s condition; and</text> </level> <level label="ii"> <text>in accordance with the timeliness requirements for determinations made by private review agents under § 15–10B–06 of this title.</text> </level> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>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.</text> </level> <level label="6"> <text>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.</text> </level> <level label="7"> <text>Each carrier shall:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>inform members of the procedure to request a referral under paragraph (1) of this subsection; and</text> </level> <level label="iii"> <text>provide the information documented under item (i) of this paragraph to the Commissioner on request.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <level label="1"> <text>Each carrier shall file with the Commissioner a copy of each of the procedures required under this section, including:</text> <level label="i"> <text>steps the carrier requires of a member to request a referral;</text> </level> <level label="ii"> <text>the carrier’s timeline for decisions; and</text> </level> <level label="iii"> <text>the carrier’s grievance procedures for denials.</text> </level> </level> <level label="2"> <text>Each carrier shall make a copy of each of the procedures filed under paragraph (1) of this subsection available to its members:</text> <level label="i"> <text>in the carrier’s online provider directory required under § 15–112(n)(1) of this title; and</text> </level> <level label="ii"> <text>on request.</text> </level> </level> </level> <level label="h"> <text>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.</text> </level> <level label="i"> <text>This section may not be construed to limit the provisions in § 19–710(p) of the Health – General Article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-831" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Authorized prescriber” has the meaning stated in § 12–101 of the Health Occupations Article.</text> </level> <level label="3"> <text>“Formulary” means a list of prescription drugs or devices that are covered by an entity subject to this section.</text> </level> <level label="4"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Member” includes a subscriber.</text> </level> </level> </level> <level label="b"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide coverage for prescription drugs and devices under individual or group contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>This section does not apply to a managed care organization as defined in § 15–101 of the Health – General Article.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>continue the same cost sharing requirements if the entity has moved the prescription drug or device to a higher deductible, copayment, or coinsurance tier.</text> </level> </level> <level label="d"> <text>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:</text> <level label="1"> <text>there is no equivalent prescription drug or device in the entity’s formulary in a lower tier;</text> </level> <level label="2"> <text>an equivalent prescription drug or device in the entity’s formulary in a lower tier:</text> <level label="i"> <text>has been ineffective in treating the disease or condition of the member; or</text> </level> <level label="ii"> <text>has caused or is likely to cause an adverse reaction or other harm to the member; or</text> </level> </level> <level label="3"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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:</text> <level label="1"> <text>notice of the change at least 30 days before the change is implemented; and</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-832" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>one home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility; and</text> </level> <level label="2"> <text>an additional home visit if prescribed by the patient’s attending physician.</text> </level> </level> <level label="c"> <text>Each entity subject to this section shall provide notice annually to its enrollees and insureds about the coverage required under this section.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-832.1" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “mastectomy” means the surgical removal of all or part of a breast as a result of breast cancer.</text> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>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:</text> <level label="i"> <text>one home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility; and</text> </level> <level label="ii"> <text>an additional home visit if prescribed by the patient’s attending physician.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <text>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:</text> <level label="1"> <text>advocating the interest of a mastectomy patient through the entity’s utilization review or appeals system;</text> </level> <level label="2"> <text>advocating more than 48 hours of inpatient hospital care for a patient with complications related to a mastectomy; or</text> </level> <level label="3"> <text>prescribing a home visit under subsection (e)(1)(ii) or (2) of this section.</text> </level> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <text>An entity subject to this section shall provide notice annually to insureds and enrollees about the coverage provided by this section.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-833" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>This section applies to health benefit plans issued under Subtitle 12 of this title.</text> </level> <level label="c"> <text>This section does not apply if:</text> <level label="1"> <text>coverage is terminated because an individual fails to pay a required premium;</text> </level> <level label="2"> <text>coverage is terminated for fraud or material misrepresentation by the individual; or</text> </level> <level label="3"> <text>any coverage provided by a succeeding health benefit plan:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>does not result in an interruption of benefits.</text> </level> </level> </level> <level label="d"> <text>During an extension period required under this section a premium may not be charged.</text> </level> <level label="e"> <level label="1"> <text>This subsection applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits under contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the date the individual ceases to be totally disabled; or</text> </level> <level label="ii"> <text>12 months after the date coverage terminates.</text> </level> </level> <level label="3"> <text>An entity subject to this subsection may at any time require the individual to provide proof of total disability.</text> </level> </level> <level label="f"> <level label="1"> <text>This subsection applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits under individual contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the date the individual is released from the care of a physician for the condition that is the basis of the claim; or</text> </level> <level label="ii"> <text>12 months after the date coverage terminates.</text> </level> </level> </level> <level label="g"> <level label="1"> <text>This subsection applies to:</text> <level label="i"> <text>group, blanket, and individual policies that limit coverage to hospital or surgical benefits on an expense-incurred basis; and</text> </level> <level label="ii"> <text>group, blanket, and individual hospital indemnity policies.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the date the individual is discharged from the hospital; or</text> </level> <level label="ii"> <text>12 months after the date coverage terminates.</text> </level> </level> </level> <level label="h"> <level label="1"> <text>This subsection applies to insurers, nonprofit health service plans, and health maintenance organizations that provide group, blanket, or individual vision benefits.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="i"> <level label="1"> <text>This subsection applies to insurers that provide group, blanket, or individual accidental death or dismemberment benefits.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>an accident occurs while the individual is covered; and</text> </level> <level label="ii"> <text>the loss occurs within 90 days after the accident.</text> </level> </level> </level> <level label="j"> <level label="1"> <text>This subsection applies to insurers, nonprofit health service plans, health maintenance organizations, and dental plan organizations that provide group, blanket, or individual dental benefits.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>begins before the date coverage terminates; and</text> </level> <level label="ii"> <text>requires two or more visits on separate days to a dentist’s office.</text> </level> </level> <level label="3"> <text>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:</text> <level label="i"> <text>for 60 days after the date coverage terminates if the orthodontist has agreed to or is receiving monthly payments; or</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-834" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-835" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“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.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <level label="1"> <text>An entity subject to this section:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>may do so through a managed care system.</text> </level> </level> <level label="2"> <text>An entity subject to this section is not required to provide reimbursement for habilitative services delivered through early intervention or school services.</text> </level> </level> <level label="d"> <text>An entity subject to this section shall provide notice annually to its insureds and enrollees about the coverage required under this section:</text> <level label="1"> <text>in print; and</text> </level> <level label="2"> <text>on its Web site.</text> </level> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-836" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The cost of a hair prosthesis required under paragraph (1) of this subsection may not exceed $350.</text> </level> </level> <level label="c"> <text>To be covered under this section, a hair prosthesis must be prescribed by the oncologist in attendance.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-837" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-838" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <level label="1"> <text>In this subsection, “hearing aid” means a device that:</text> <level label="i"> <text>is of a design and circuitry to optimize audibility and listening skills in the environment commonly experienced by children; and</text> </level> <level label="ii"> <text>is nondisposable.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-838.1" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “hearing aid” means a device that:</text> <level label="1"> <text>is of a design and circuitry to optimize audibility and listening skills in the environment commonly experienced by adults; and</text> </level> <level label="2"> <text>is nondisposable.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>prescribed, fitted, and dispensed by a licensed audiologist; or</text> </level> <level label="2"> <text>ordered, fitted, and dispensed by a licensed hearing aid dispenser.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-839" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Morbid obesity” means a body mass index that is:</text> <level label="i"> <text>greater than 40 kilograms per meter squared; or</text> </level> <level label="ii"> <text>equal to or greater than 35 kilograms per meter squared with a comorbid medical condition, including hypertension, a cardiopulmonary condition, sleep apnea, or diabetes.</text> </level> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>managed care organizations, as defined in § 15-101 of the Health - General Article.</text> </level> </level> <level label="c"> <text>An entity subject to this section shall provide coverage for the surgical treatment of morbid obesity that is:</text> <level label="1"> <text>recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity; and</text> </level> <level label="2"> <text>consistent with guidelines approved by the National Institutes of Health.</text> </level> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-840" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “residential crisis services” means intensive mental health and support services that are:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>designed to prevent a psychiatric inpatient admission, provide an alternative to psychiatric inpatient admission, or shorten the length of inpatient stay;</text> </level> <level label="3"> <text>provided out of the individual’s residence on a short–term basis in a community–based residential setting; and</text> </level> <level label="4"> <text>provided by entities that are licensed by the Maryland Department of Health to provide residential crisis services.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <level label="1"> <text>An entity subject to this section shall provide coverage for medically necessary residential crisis services.</text> </level> <level label="2"> <text>The services required under this section may be delivered under a managed care system.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-841" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Authorized prescriber” has the meaning stated in § 12-101 of the Health Occupations Article.</text> </level> <level label="3"> <level label="i"> <text>“Nicotine replacement therapy” means a product that:</text> <level label="1"> <text>is used to deliver nicotine to an individual attempting to cease the use of tobacco products; and</text> </level> <level label="2"> <text>is obtained under a prescription written by an authorized prescriber.</text> </level> </level> <level label="ii"> <text>“Nicotine replacement therapy” does not include any over-the-counter product that may be obtained without a prescription.</text> </level> </level> <level label="4"> <text>“Tobacco product” has the meaning stated in § 10-101 of the Criminal Law Article.</text> </level> </level> <level label="b"> <level label="1"> <text>This subsection applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide coverage for prescription drugs to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>An entity subject to this subsection shall provide coverage for:</text> <level label="i"> <text>except for a drug that may be obtained over-the-counter without a prescription, any drug that:</text> <level label="1"> <text>is approved by the United States Food and Drug Administration as an aid for the cessation of the use of tobacco products; and</text> </level> <level label="2"> <text>is obtained under a prescription written by an authorized prescriber; and</text> </level> </level> <level label="ii"> <text>two 90-day courses of nicotine replacement therapy during each policy year.</text> </level> </level> <level label="3"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-842" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide coverage for prescription drugs and devices under contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-843" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, and surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <level label="1"> <text>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:</text> <level label="i"> <text>Immunoglobulin E and non–Immunoglobulin E mediated allergies to multiple food proteins;</text> </level> <level label="ii"> <text>severe food protein induced enterocolitis syndrome;</text> </level> <level label="iii"> <text>eosinophilic disorders, as evidenced by the results of a biopsy; and</text> </level> <level label="iv"> <text>impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-844" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section, “prosthesis” means an artificial device to replace, in whole or in part, a leg, an arm, or an eye.</text> </level> <level label="2"> <text>“Prosthesis” includes a custom–designed, –fabricated, –fitted, or –modified device to treat partial or total limb loss for purposes of restoring physiological function.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>An entity subject to this section shall provide once annually coverage for:</text> <level label="1"> <text>prostheses;</text> </level> <level label="2"> <text>components of prostheses;</text> </level> <level label="3"> <text>repairs to prostheses; and</text> </level> <level label="4"> <text>subject to subsection (d) of this section, replacements of prostheses or prosthesis components.</text> </level> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <text>because of a change in the physiological condition of the patient;</text> </level> <level label="ii"> <text>unless necessitated by misuse, because of an irreparable change in the condition of the prosthesis or a component of the prosthesis; or</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The covered benefits under this section include prostheses determined by a treating health care provider to be medically necessary for:</text> <level label="i"> <text>completing activities of daily living;</text> </level> <level label="ii"> <text>essential job–related activities; or</text> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="h"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-845" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide coverage for prescription eye drops under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>An entity subject to this section shall provide coverage for a refill of prescription eye drops:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>if:</text> <level label="i"> <text>the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>the prescription eye drops prescribed by the health care practitioner are a covered benefit under the policy or contract of the insured.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-846" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “cancer chemotherapy” means medication that is prescribed by a licensed physician to kill or slow the growth of cancer cells.</text> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-847" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“Complex or chronic medical condition” means a physical, behavioral, or developmental condition that:</text> <level label="1"> <text>may have no known cure;</text> </level> <level label="2"> <text>is progressive; or</text> </level> <level label="3"> <text>can be debilitating or fatal if left untreated or undertreated.</text> </level> </level> <level label="ii"> <text>“Complex or chronic medical condition” includes:</text> <level label="1"> <text>multiple sclerosis;</text> </level> <level label="2"> <text>hepatitis C; and</text> </level> <level label="3"> <text>rheumatoid arthritis.</text> </level> </level> </level> <level label="3"> <text>“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.</text> </level> <level label="4"> <level label="i"> <text>“Rare medical condition” means a disease or condition that affects fewer than:</text> <level label="1"> <text>200,000 individuals in the United States; or</text> </level> <level label="2"> <text>approximately 1 in 1,500 individuals worldwide.</text> </level> </level> <level label="ii"> <text>“Rare medical condition” includes:</text> <level label="1"> <text>cystic fibrosis;</text> </level> <level label="2"> <text>hemophilia; and</text> </level> <level label="3"> <text>multiple myeloma.</text> </level> </level> </level> <level label="5"> <level label="i"> <text>“Specialty drug” means a prescription drug that:</text> <level label="1"> <text>is prescribed for an individual with a complex or chronic medical condition or a rare medical condition;</text> </level> <level label="2"> <text>costs $600 or more for up to a 30–day supply;</text> </level> <level label="3"> <text>is not typically stocked at retail pharmacies; and</text> </level> <level label="4"> <level label="A"> <text>requires a difficult or unusual process of delivery to the patient in the preparation, handling, storage, inventory, or distribution of the drug; or</text> </level> </level> <level label="B"> <text>requires enhanced patient education, management, or support, beyond those required for traditional dispensing, before or after administration of the drug.</text> </level> </level> <level label="ii"> <text>“Specialty drug” does not include a prescription drug prescribed to treat diabetes, HIV, or AIDS.</text> </level> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide coverage for prescription drugs under individual or group contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <text>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:</text> <level label="1"> <text>a designated pharmacy or other source authorized under the Health Occupations Article to dispense or administer prescription drugs; or</text> </level> <level label="2"> <text>a pharmacy participating in the entity’s provider network, if the entity determines that the pharmacy:</text> <level label="i"> <text>meets the entity’s performance standards; and</text> </level> <level label="ii"> <text>accepts the entity’s network reimbursement rates.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>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:</text> <level label="i"> <text>the pharmacy is owned by a federally qualified health center, as defined in 42 U.S.C. § 254B;</text> </level> <level label="ii"> <text>the federally qualified health center provides integrated and coordinated medical and pharmaceutical services to hepatitis C patients; and</text> </level> <level label="iii"> <text>the prescription drugs are covered specialty drugs for the treatment of hepatitis C.</text> </level> </level> <level label="2"> <text>An entity subject to this section may not unreasonably withhold approval of a pharmacy’s application under paragraph (1) of this subsection.</text> </level> </level> <level label="f"> <text>An entity subject to this section may provide coverage for specialty drugs through a managed care system.</text> </level> <level label="g"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="h"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-847.1" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide coverage for prescription drugs under individual group contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-847.2" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “specialty drug” has the meaning stated in § 15–847 of this subtitle.</text> </level> <level label="b"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide coverage for prescription drugs under individual or group contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>the provider that administers or dispenses the covered specialty drug:</text> <level label="i"> <text>is an in–network provider of covered oncology services; and</text> </level> <level label="ii"> <text>complies with State regulations for the administering and dispensing of specialty drugs; and</text> </level> </level> <level label="2"> <text>the covered specialty drug is:</text> <level label="i"> <text>auto–injected or an oral targeted immune modulator; or</text> </level> <level label="ii"> <text>an oral medication that:</text> <level label="1"> <text>requires complex dosing based on clinical presentation; or</text> </level> <level label="2"> <text>is used concomitantly with other infusion or radiation therapies.</text> </level> </level> </level> </level> <level label="d"> <level label="1"> <text>Subject to subsection (f) of this section, the reimbursement rate for specialty drugs covered under this section shall be:</text> <level label="i"> <text>agreed to by the covered, in–network provider and the entity subject to this section; and</text> </level> <level label="ii"> <text>billed at a nonhospital level of care or place of service.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-848" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-849" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“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:</text> <level label="i"> <text>is in immediate release or extended release form; or</text> </level> <level label="ii"> <text>contains other drug substances.</text> </level> </level> </level> <level label="b"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide coverage for prescription drugs under individual or group contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <text>An entity subject to this section shall provide coverage for:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-850" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “opioid antagonist” means:</text> <level label="1"> <text>naloxone hydrochloride; or</text> </level> <level label="2"> <text>any other similarly acting and equally safe drug approved by the federal Food and Drug Administration for the treatment of a drug overdose.</text> </level> </level> <level label="b"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide coverage for prescription drugs under individual or group contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-851" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>An entity subject to this section may not apply a prior authorization requirement for a prescription drug:</text> <level label="1"> <text>when used for treatment of an opioid use disorder; and</text> </level> <level label="2"> <text>that contains methadone, buprenorphine, or naltrexone.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-852" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“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.</text> </level> </level> <level label="b"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide coverage for prescription drugs and devices under contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>the prescriber or the pharmacist determines dispensing a partial supply of a prescription drug to be in the best interest of the member;</text> </level> <level label="2"> <text>the prescription drug is anticipated to be required for more than 3 months;</text> </level> <level label="3"> <text>the member requests or agrees to a partial supply for the purpose of synchronizing the dispensing of the member’s prescription drugs;</text> </level> <level label="4"> <text>the prescription drug is not a Schedule II controlled dangerous substance; and</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="d"> <text>Subject to subsection (c) of this section, an entity subject to this section:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>shall allow an in–network pharmacy to override any denial codes indicating that a prescription is being refilled too soon.</text> </level> </level> <level label="e"> <text>Subject to subsection (c) of this section, an entity subject to this section:</text> <level label="1"> <text>may not use a payment structure that incorporates prorated dispensing fees for dispensing a partial supply of a prescription drug; and</text> </level> <level label="2"> <text>shall pay an in–network pharmacy a full dispensing fee for dispensing a partial supply of a prescription drug under this section, regardless of:</text> <level label="i"> <text>any prorated copayment or coinsurance amount charged to a member; or</text> </level> <level label="ii"> <text>any fee paid to the pharmacy for synchronizing a member’s prescriptions.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-853" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section, “gradient compression garment” means a garment that:</text> <level label="i"> <text>is used for the treatment of lymphedema;</text> </level> <level label="ii"> <text>requires a prescription; and</text> </level> <level label="iii"> <text>is custom fit for the individual for whom the garment is prescribed.</text> </level> </level> <level label="2"> <text>“Gradient compression garment” does not include disposable medical supplies, including over–the–counter compression or elastic knee–high or other stocking products.</text> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-854" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>This section does not apply to a managed care organization as defined in § 15–101 of the Health – General Article.</text> </level> </level> <level label="b"> <level label="1"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <level label="1"> <text>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:</text> <level label="i"> <text>in writing to any insured who is prescribed the prescription drug; and</text> </level> <level label="ii"> <text>either in writing or electronically to all contracted health care providers.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <level label="1"> <text>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:</text> <level label="i"> <text>prescribed at the same time as part of an insured’s treatment plan; and</text> </level> <level label="ii"> <text>manufactured by the same manufacturer.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="g"> <level label="1"> <text>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:</text> <level label="i"> <text>the prescription drug is:</text> <level label="1"> <text>an immune globulin (human) as defined in 21 C.F.R. § 640.100; or</text> </level> <level label="2"> <text>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;</text> </level> </level> <level label="ii"> <text>the entity previously approved a prior authorization for the prescription drug for the insured;</text> </level> <level label="iii"> <text>the insured has been treated with the prescription drug without interruption since the initial approval of the prior authorization; and</text> </level> <level label="iv"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-854.1" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Course of treatment” means treatment that:</text> <level label="i"> <text>is prescribed to treat or ordered for the treatment of an insured with a specific condition;</text> </level> <level label="ii"> <text>is outlined and agreed to by the insured and the health care provider before the treatment begins; and</text> </level> <level label="iii"> <text>may be part of a treatment plan.</text> </level> </level> </level> <level label="b"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <text>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:</text> <level label="i"> <text>for a period of time that is as long as necessary to avoid disruptions in care; and</text> </level> <level label="ii"> <text>determined in accordance with applicable coverage criteria, the insured’s medical history, and the health care provider’s recommendation.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-855" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>autoimmune encephalitis;</text> </level> <level label="ii"> <text>pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections; or</text> </level> <level label="iii"> <text>pediatric acute onset neuropsychiatric syndrome.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-856" effective_note="EFFECTIVE UNTIL DECEMBER 31, 2022 PER CHAPTERS 29 AND 31 OF 2021 SPECIAL SESSION" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“COVID–19” means, interchangeably and collectively, the coronavirus known as COVID–19 or 2019–nCoV and the SARS–CoV–2 virus.</text> </level> <level label="3"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“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.</text> </level> </level> <level label="4"> <text>“Health benefit plan”:</text> <level label="i"> <text>for a small employer plan, has the meaning stated in § 15–1201 of this title; and</text> </level> <level label="ii"> <text>for an individual plan, has the meaning stated in § 15–1301 of this title.</text> </level> </level> <level label="5"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Member” includes a subscriber.</text> </level> </level> </level> <level label="b"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-857" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide labor and delivery coverage to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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).</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>cover abortion care services without:</text> <level label="i"> <text>a deductible, coinsurance, copayment, or any other cost–sharing requirement; and</text> </level> <level label="ii"> <text>restrictions that are inconsistent with the protected rights under Title 20, Subtitle 2 of the Health – General Article; and</text> </level> </level> <level label="2"> <text>provide information to consumers about abortion care coverage using the terminology “abortion care” to describe coverage.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-858" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide coverage for prescription drugs under individual or group contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-859" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Biomarker” includes gene mutations, characteristics of genes, or protein expression.</text> </level> </level> <level label="3"> <level label="i"> <text>“Biomarker testing” is the analysis of a patient’s tissue, blood, or other biospecimen for the presence of a biomarker, the results of which:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>include both information that is actionable and some information that cannot be immediately used in the formulation of a clinical decision.</text> </level> </level> <level label="ii"> <text>“Biomarker testing” includes single–analyte tests, multi–plex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing.</text> </level> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>cleared or approved by the U.S. Food and Drug Administration;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>covered under a Centers for Medicare and Medicaid Services National Coverage Determination or Medicare Administrative Contractor Local Coverage Determination; or</text> </level> <level label="5"> <text>supported by nationally recognized clinical practice guidelines that are:</text> <level label="i"> <text>developed by independent organizations or medical professional societies using a transparent methodology and reporting structure and that have a conflict of interest policy; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-860" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The coverage required under paragraph (1) of this subsection:</text> <level label="i"> <text>shall include diagnostic ultrasound, magnetic resonance imaging, computed tomography, and image–guided biopsy; and</text> </level> <level label="ii"> <text>may not be subject to a prior authorization requirement.</text> </level> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-861" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>In this section, “special pediatric hospital” has the meaning stated in § 15–101 of the Health – General Article.</text> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="c"> <text>An entity subject to this section may not require prior authorization for a transfer to a special pediatric hospital.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-862" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>An entity subject to this section that covers the delivery of anesthesia for a procedure for which a licensed medical professional issues an order:</text> <level label="1"> <text>shall provide coverage for:</text> <level label="i"> <text>the delivery of anesthesia for the entire duration of the procedure; and</text> </level> <level label="ii"> <text>medical care related to the delivery of anesthesia for the procedure that is provided immediately before and after the procedure; and</text> </level> </level> <level label="2"> <text>may not establish, implement, or enforce a policy, practice, or procedure that places time limitations on the delivery of anesthesia.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-863" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits"> <level label="a"> <text>This section applies to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-864" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits" /> <section article="gin" article_name="Insurance" number="15-865" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits" /> <section article="gin" article_name="Insurance" number="15-866" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits" /> <section article="gin" article_name="Insurance" number="15-867" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits" /> <section article="gin" article_name="Insurance" number="15-901" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“Applicant” means:</text> <level label="1"> <text>for an individual Medicare supplement policy or subscriber contract, the individual who seeks to contract for insurance benefits; or</text> </level> <level label="2"> <text>for a group Medicare supplement policy or subscriber contract, the proposed certificate holder.</text> </level> </level> <level label="c"> <text>“Carrier” means an insurer, nonprofit health service plan, or fraternal benefit society that is authorized to issue health insurance policies under this article.</text> </level> <level label="d"> <text>“Certificate” means a certificate that is delivered or issued for delivery in the State under a group Medicare supplement policy.</text> </level> <level label="e"> <text>“Certificate form” means the form on which the certificate is delivered or issued for delivery in the State by the carrier.</text> </level> <level label="f"> <text>“CMS” means the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services.</text> </level> <level label="g"> <text>“Medicaid” means the Health Insurance for the Aged Act, Title XIX of the Social Security Amendments of 1965, as amended.</text> </level> <level label="h"> <text>“Medicare” means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as amended.</text> </level> <level label="i"> <text>“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.</text> </level> <level label="j"> <text>“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.</text> </level> <level label="k"> <level label="1"> <text>“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.</text> </level> <level label="2"> <text>“Medicare supplement policy” or “Medigap policy” does not include:</text> <level label="i"> <text>a policy that is issued pursuant to a contract under § 1876 of the federal Social Security Act, 42 U.S.C. § 1395mm; or</text> </level> <level label="ii"> <text>a policy that is issued under a demonstration project authorized pursuant to amendments to the federal Social Security Act.</text> </level> </level> </level> <level label="l"> <text>“Policy” includes:</text> <level label="1"> <text>a policy that is issued to an individual;</text> </level> <level label="2"> <text>a certificate, as that term is used in Title 14, Subtitle 1 of this article, that is issued to an individual subscriber;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>a group policy authorized to be issued under this article.</text> </level> </level> <level label="m"> <text>“Policy form” means the form on which the policy is delivered or issued for delivery in the State by the carrier.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-902" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-903" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>Notwithstanding any other provision to the contrary, this subtitle applies to:</text> <level label="1"> <text>Medicare supplement policies and subscriber contracts that are delivered or issued for delivery in the State after July 1, 1992;</text> </level> <level label="2"> <text>certificates that are issued under group Medicare supplement policies or subscriber contracts, which certificates have been delivered or issued for delivery in the State;</text> </level> <level label="3"> <text>individual or group Medicare supplement policies and certificates that are issued by nonprofit health service plans under Title 14, Subtitle 1 of this article;</text> </level> <level label="4"> <text>Medicare supplement policies and certificates that are issued by fraternal benefit societies under Title 8, Subtitle 4 of this article; and</text> </level> <level label="5"> <text>Medicare supplement group or blanket policies and certificates that are issued by insurers subject to Subtitle 3 of this title.</text> </level> </level> <level label="b"> <text>This subtitle does not apply to a policy of:</text> <level label="1"> <text>one or more employers or labor organizations; or</text> </level> <level label="2"> <text>the trustees of a fund established by one or more employers or labor organizations for employees, members, former employees, or former members.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-904" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>A carrier may not issue, deliver, or renew a Medicare supplement policy in the State unless the Medicare supplement policy complies with this subtitle.</text> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="c"> <text>The Commissioner may adopt regulations, in consultation with the Secretary of Health, to establish the requirements of the Medicare Select Program.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-905" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <text>A carrier shall restore any benefit that was eliminated from a Medicare supplement policy because of the federal Medicare Catastrophic Coverage Act of 1988.</text> </section> <section article="gin" article_name="Insurance" number="15-906" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>A Medicare supplement policy shall provide the minimum benefits required by federal law.</text> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <level label="1"> <text>A Medicare supplement policy, contract, or certificate in force in the State may not provide benefits that duplicate benefits provided by Medicare.</text> </level> <level label="2"> <text>Unless approved by the Commissioner, a Medicare supplement policy may not be offered at an introductory premium rate.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-907" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-908" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <text>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:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>comply with the applicable provisions of this article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-909" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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:</text> <level label="i"> <text>was enrolled in Medicare Part B while enrolled in the Maryland Medical Assistance Program;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>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</text> </level> <level label="iv"> <text>submits evidence of the date of termination or disenrollment from the Maryland Medical Assistance Program with the application for a Medicare supplement policy.</text> </level> </level> <level label="4"> <text>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:</text> <level label="i"> <text>became eligible for Medicare before January 1, 2020;</text> </level> <level label="ii"> <text>qualifies under any federal special enrollment period guaranteed issue right, including for plans issued on or after January 1, 2020;</text> </level> <level label="iii"> <text>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</text> </level> <level label="iv"> <text>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.</text> </level> </level> <level label="5"> <level label="i"> <text>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:</text> <level label="1"> <text>during the 6–month period following the applicant’s enrollment in Part B of Medicare; or</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="ii"> <text>For a Medicare supplement policy plan A or D required to be made available under subparagraph (i) of this paragraph, a carrier:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="6"> <text>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.</text> </level> <level label="7"> <text>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.</text> </level> <level label="8"> <level label="i"> <text>This paragraph applies only on and after July 1, 2023.</text> </level> <level label="ii"> <text>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.</text> </level> <level label="iii"> <level label="1"> <text>For purposes of this paragraph, a Medicare supplement policy has equal or lesser benefits unless:</text> </level> <level label="A"> <text>it contains one or more significant benefits not included in the Medicare supplement policy being replaced; or</text> </level> <level label="B"> <text>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.</text> </level> <level label="2"> <text>The Commissioner shall adopt regulations establishing a matrix for identifying which Medicare supplement policies have equal or lesser benefits.</text> </level> </level> <level label="iv"> <text>For a Medicare supplement policy required to be made available under subparagraph (ii) of this paragraph, a carrier may not:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="v"> <text>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.</text> </level> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <level label="1"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>The carrier shall offer the certificate holder at least the following:</text> <level label="1"> <text>an individual Medicare supplement policy that provides for continuation of the benefits contained in the group policy; or</text> </level> <level label="2"> <text>an individual Medicare supplement policy that provides only the benefits that are required under § 15–906(a) of this subtitle.</text> </level> </level> </level> <level label="2"> <text>If membership in a group is terminated, the carrier:</text> <level label="i"> <text>shall offer the certificate holder the conversion options under paragraph (1) of this subsection; or</text> </level> <level label="ii"> <text>at the option of the group policyholder, shall offer the certificate holder a continuation of coverage under the group Medicare supplement policy.</text> </level> </level> <level label="3"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-910" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>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:</text> <level label="1"> <text>return the Medicare supplement policy or certificate within 30 days after its delivery; and</text> </level> <level label="2"> <text>receive a refund of the premium if after examination of the Medicare supplement policy or certificate, the applicant is not satisfied for any reason.</text> </level> </level> <level label="b"> <text>The carrier shall pay a refund made under this section directly to the applicant in a timely manner.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-911" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>Medicare supplement policies shall return aggregate benefits that are reasonable in relation to the premium charged.</text> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="d"> <text>The minimum acceptable loss ratios for Medicare supplement policies are:</text> <level label="1"> <text>for group Medicare supplement policies, at least 75% of the aggregate amount of premiums earned; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-912" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>The Commissioner shall adopt reasonable regulations to establish specific standards for policy provisions of Medicare supplement policies and certificates.</text> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>The standards may cover, but are not limited to:</text> <level label="1"> <text>terms of renewability;</text> </level> <level label="2"> <text>initial and subsequent conditions of eligibility;</text> </level> <level label="3"> <text>nonduplication of coverage;</text> </level> <level label="4"> <text>probationary periods;</text> </level> <level label="5"> <text>benefit limitations, exceptions, and reductions;</text> </level> <level label="6"> <text>elimination periods;</text> </level> <level label="7"> <text>replacement requirements;</text> </level> <level label="8"> <text>recurrent conditions;</text> </level> <level label="9"> <text>definitions of terms; and</text> </level> <level label="10"> <text>any other provisions required under federal Medicare law or CMS regulations.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-913" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-914" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-915" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>The Commissioner shall adopt reasonable regulations as necessary to conform Medicare supplement policies and certificates to the requirements of federal law and regulations.</text> </level> <level label="b"> <text>The regulations may include, but are not limited to, provisions that:</text> <level label="1"> <text>require rate adjustments, credits, or refunds if the Medicare supplement policies or certificates do not meet loss ratio requirements;</text> </level> <level label="2"> <text>establish a uniform methodology for calculating and reporting loss ratios;</text> </level> <level label="3"> <text>ensure public access to policies, premiums, and loss ratio information of carriers of Medicare supplement insurance;</text> </level> <level label="4"> <text>establish a process for approving or disapproving policy forms and certificate forms; and</text> </level> <level label="5"> <text>establish a policy for holding public hearings before approval of premium increases and a process for approving or disapproving proposed schedules of premium changes.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-916" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>The buyer’s guide shall:</text> <level label="1"> <text>contain an outline of Medicare coverage; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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:</text> <level label="1"> <text>before accepting an application;</text> </level> <level label="2"> <text>when an existing policy is converted to a Medicare supplement policy; and</text> </level> <level label="3"> <text>at any other time required by the Commissioner by regulation.</text> </level> </level> <level label="e"> <text>A carrier shall provide:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <level label="1"> <text>The text of the Medicare supplement buyer’s guide shall be as the Commissioner submits for publication under subsection (c) of this section.</text> </level> <level label="2"> <text>The form of the Medicare supplement buyer’s guide shall be as required by the Commissioner by regulation.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-917" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <text>In this subsection, “format” means style, arrangements, and overall appearance, including the size, color, and prominence of type and arrangement of text and captions.</text> </level> <level label="2"> <text>The Commissioner shall prescribe the format and content of the outline of coverage required by this section.</text> </level> <level label="3"> <text>The outline of coverage shall include:</text> <level label="i"> <text>a description of the principal benefits and coverage provided in the Medicare supplement policy;</text> </level> <level label="ii"> <text>a statement of the exceptions, reductions, and limitations contained in the Medicare supplement policy;</text> </level> <level label="iii"> <text>a statement of the renewal provisions, including any reservation by the carrier of a right to change premiums;</text> </level> <level label="iv"> <text>disclosure of the existence of any automatic renewal premium increases based on the policyholder’s age; and</text> </level> <level label="v"> <text>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.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-918" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-919" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The written statement shall be given before the carrier or insurance producer accepts an application.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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:</text> <text>“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”.</text> </level> <level label="2"> <text>The statement required by paragraph (1) of this subsection shall be printed on or attached to the first page of:</text> <level label="i"> <text>the policy form or certificate; or</text> </level> <level label="ii"> <text>an outline of coverage delivered to the individual covered under the policy or certificate.</text> </level> </level> <level label="3"> <text>A carrier or insurance producer of a carrier need not provide the statement required under paragraph (1) of this subsection for:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>a disability income policy; or</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="4"> <text>Notwithstanding paragraph (1) of this subsection, the Commissioner shall adopt regulations necessary to conform this subsection to the requirements of applicable federal law.</text> </level> </level> <level label="e"> <text>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:</text> <text>“This is an accident only policy. It does not pay benefits for loss due to sickness”.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-920" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-921" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-922" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <level label="1"> <text>In this section, “compensation” means any pecuniary or nonpecuniary remuneration related to the sale or renewal of a Medicare supplement policy or certificate.</text> </level> <level label="2"> <text>“Compensation” includes bonuses, gifts, and finders’ fees.</text> </level> <level label="3"> <text>“Compensation” does not include noncash prizes or awards.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-922.1" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>This section applies to a Medicare supplement policy issued:</text> <level label="1"> <text>under § 15–909(b)(6) of this subtitle; or</text> </level> <level label="2"> <text>to an individual at least 65 years old.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-923" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-924" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <text>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:</text> <level label="i"> <text>is already covered by an existing Medicare supplement policy; and</text> </level> <level label="ii"> <text>is entitled to Medicaid benefits.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>When soliciting or advertising the sale of a health insurance policy to an individual eligible for Medicare, a carrier or insurance producer may not:</text> <level label="1"> <text>represent or imply that the carrier or insurance producer represents, works for, or is compensated by a federal, State, or local government agency;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>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:</text> <level label="i"> <text>purchase, amend, lapse, surrender, forfeit, change, duplicate, or not renew coverage already in force;</text> </level> <level label="ii"> <text>replace a policy that is only technically at variance with the policy being offered by the carrier or insurance producer; or</text> </level> <level label="iii"> <text>take out a policy with another carrier.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-925" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-926" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>On request from CMS, the Commissioner may provide to CMS any information about Medicare supplement policies that are issued in the State.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-927" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-928" title_number="15" title_name="Health Insurance" subtitle_number="9" subtitle_name="Medicare Supplement Act"> <text>This subtitle is the Medicare Supplement Act.</text> </section> <section article="gin" article_name="Insurance" number="15-1001" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <level label="a"> <text>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:</text> <level label="1"> <text>an authorized insurer that provides health insurance in the State;</text> </level> <level label="2"> <text>a nonprofit health service plan;</text> </level> <level label="3"> <text>a health maintenance organization;</text> </level> <level label="4"> <text>a dental plan organization; or</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="b"> <level label="1"> <text>Subject to paragraph (2) of this subsection, each entity subject to this section shall:</text> <level label="i"> <level label="1"> <text>have a certificate issued under Subtitle 10B of this title; or</text> </level> <level label="2"> <text>contract with a private review agent that has a certificate issued under Subtitle 10B of this title; and</text> </level> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>the treating provider; or</text> </level> <level label="2"> <text>when hospital services are provided, the hospital utilization review program approved under § 19-319(d) of the Health - General Article.</text> </level> </level> <level label="d"> <text>An entity subject to this section may not:</text> <level label="1"> <text>act as a private review agent without holding a certificate issued under Subtitle 10B of this title; or</text> </level> <level label="2"> <text>use a private review agent that does not hold a certificate issued under Subtitle 10B of this title.</text> </level> </level> <level label="e"> <text>An entity that violates any provision of this section is subject to the penalties provided under § 15-10B-12 of this title.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1002" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1003" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <level label="i"> <text>“Health care practitioner” means a person that is licensed or certified under the Health Occupations Article and reimbursed by a third party payor.</text> </level> <level label="ii"> <text>“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.</text> </level> </level> <level label="3"> <text>“Hospital” has the meaning stated in § 19-301 of the Health - General Article.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>The Commissioner shall adopt by regulation a uniform claims form for reimbursement of health care practitioners’ services.</text> </level> <level label="d"> <level label="1"> <text>The Commissioner shall adopt by regulation:</text> <level label="i"> <text>a definition of a clean claim, including:</text> <level label="1"> <text>the essential data elements that must be completed on the uniform claims form; and</text> </level> <level label="2"> <text>uniform standards for attachments to the uniform claims form;</text> </level> </level> <level label="ii"> <text>permissible categories of disputed claims for which additional information may be requested under §§ 15-1004(c) and 15-1005(c) of this subtitle; and</text> </level> <level label="iii"> <text>standards for determining when a claim is considered received for reimbursement.</text> </level> </level> <level label="2"> <text>In adopting the regulations required under paragraph (1)(i) of this subsection, the Commissioner shall consider:</text> <level label="i"> <text>standards for attachments required by the federal Centers for Medicare and Medicaid Services for the Medicare Program;</text> </level> <level label="ii"> <text>standards used by insurance carriers, nonprofit health service plans, and health maintenance organizations in the State; and</text> </level> <level label="iii"> <text>federal regulations adopted under the Health Insurance Portability and Accountability Act.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1004" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <level label="a"> <text>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:</text> <level label="1"> <text>shall accept the uniform claims form and any attachments approved or adopted by the Commissioner under § 15–1003 of this subtitle:</text> <level label="i"> <text>as a properly filed claim with all necessary documentation; and</text> </level> <level label="ii"> <text>as the sole instrument for reimbursement; and</text> </level> </level> <level label="2"> <text>may not impose as a condition of reimbursement a requirement to:</text> <level label="i"> <text>modify the uniform claims form or its content; or</text> </level> <level label="ii"> <text>submit additional claims forms.</text> </level> </level> </level> <level label="b"> <level label="1"> <text>A uniform claims form submitted under this section shall be completed properly and may be submitted by electronic transfer.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <text>the address where the claims should be sent for processing;</text> </level> <level label="ii"> <text>the telephone number at which providers’ questions and concerns regarding claims may be addressed;</text> </level> <level label="iii"> <text>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</text> </level> <level label="iv"> <text>the address and telephone number of any separate claims processing center for specific types of applicable services.</text> </level> </level> <level label="2"> <text>If an insurer, nonprofit health service plan, or health maintenance organization has delegated its claims processing function to a third party, the delegation agreement:</text> <level label="i"> <text>shall require the claims processing entity to comply with the requirements of this subtitle; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="f"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1005" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <level label="a"> <text>In this section, “clean claim” means a claim for reimbursement, as defined in regulations adopted by the Commissioner under § 15–1003 of this subtitle.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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:</text> <level label="1"> <text>mail or otherwise transmit payment for the claim in accordance with this section; or</text> </level> <level label="2"> <text>send a notice of receipt and status of the claim that states:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>that the claim is not clean and the specific additional information necessary for the claim to be considered a clean claim.</text> </level> </level> </level> <level label="d"> <level label="1"> <level label="i"> <text>In this subsection, “credit card” means a credit, debit, prepaid, or stored–value card used to make a payment through a private card network.</text> </level> <level label="ii"> <text>“Credit card” includes a method of payment to a provider where no physical card is presented.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the insurer, nonprofit health service plan, or health maintenance organization notifies the provider in advance of the payment that:</text> <level label="1"> <text>a fee or similar charge associated with the use of the credit card or electronic funds transfer payment method will apply; and</text> </level> <level label="2"> <text>the provider will need to consult the provider’s merchant processor or financial institution for the specific rates;</text> </level> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="3"> <text>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.</text> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="f"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>mail or otherwise transmit payment for any undisputed portion of the claim in accordance with this section; and</text> </level> <level label="ii"> <text>comply with subsection (c)(1) or (2)(i) of this section within 30 days after receipt of the requested additional information.</text> </level> </level> <level label="3"> <text>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.</text> </level> </level> <level label="g"> <level label="1"> <text>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:</text> <level label="i"> <level label="1"> <text>5% from the 31st day through the 60th day;</text> </level> </level> <level label="ii"> <text>2% from the 61st day through the 120th day; and</text> </level> <level label="iii"> <level label="2"> <text>5% after the 120th day.</text> </level> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="h"> <text>An insurer, nonprofit health service plan, or health maintenance organization that violates a provision of this section is subject to:</text> <level label="1"> <text>a fine not exceeding $500 for each violation that is arbitrary and capricious, based on all available information; and</text> </level> <level label="2"> <text>the penalties prescribed under § 4–113(d) of this article for violations committed with a frequency that indicates a general business practice.</text> </level> </level> <level label="i"> <level label="1"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1006" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>The notice given by an insurer under this section is subject to 45 C.F.R. § 164.522(b).</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1007" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>The summary explanation of benefits required under subsection (b) of this section shall provide a summary of:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>the amount paid by the entity for each claim filed; and</text> </level> <level label="3"> <text>the balance owed by the insured individual for each claim filed.</text> </level> </level> <level label="d"> <text>The explanation of benefits required under this section is subject to 45 C.F.R. § 164.522(b).</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1008" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization;</text> </level> <level label="v"> <text>a managed care organization, as defined in § 15–101 of the Health – General Article; or</text> </level> <level label="vi"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="3"> <text>“Code” means:</text> <level label="i"> <text>the applicable current procedural terminology (CPT) code, as adopted by the American Medical Association;</text> </level> <level label="ii"> <text>if for a dental service, the applicable code adopted by the American Dental Association; or</text> </level> <level label="iii"> <text>another applicable code under an appropriate uniform coding scheme used by a carrier in accordance with this section.</text> </level> </level> <level label="4"> <text>“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.</text> </level> <level label="5"> <text>“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.</text> </level> <level label="6"> <text>“Reimbursement” means payments made to a health care provider by a carrier on either a fee–for–service, capitated, or premium basis.</text> </level> </level> <level label="b"> <text>This section does not apply to an adjustment to reimbursement:</text> <level label="1"> <text>made as part of an annual contracted reconciliation of a risk sharing arrangement under an administrative service provider contract; or</text> </level> <level label="2"> <text>made as part of a two–sided incentive arrangement that complies with § 15–113 of this title.</text> </level> </level> <level label="c"> <level label="1"> <text>If a carrier retroactively denies reimbursement to a health care provider, the carrier:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>The provisions of subsection (c)(1) of this section do not apply if a carrier retroactively denies reimbursement to a health care provider because:</text> <level label="i"> <text>the information submitted to the carrier was fraudulent;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>the claim submitted to the carrier was a duplicate claim; or</text> </level> <level label="iv"> <text>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.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="f"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1009" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <level label="a"> <text>In this section, “carrier” means:</text> <level label="1"> <text>an insurer;</text> </level> <level label="2"> <text>a nonprofit health service plan;</text> </level> <level label="3"> <text>a health maintenance organization;</text> </level> <level label="4"> <text>a dental plan organization; or</text> </level> <level label="5"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>the information submitted to the carrier regarding the service to be delivered to the patient was fraudulent or intentionally misrepresentative;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>a planned course of treatment for the patient that was approved by the carrier was not substantially followed by the health care provider; or</text> </level> <level label="4"> <text>on the date the preauthorized or approved service was delivered:</text> <level label="i"> <text>the patient was not covered by the carrier;</text> </level> <level label="ii"> <text>the carrier maintained an automated eligibility verification system that was available to the contracting provider by telephone or via the Internet; and</text> </level> <level label="iii"> <text>according to the verification system, the patient was not covered by the carrier.</text> </level> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>the patient is in the second or third month of a grace period under 45 C.F.R. § 156.270(d);</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>according to the verification system, the provider is informed that:</text> <level label="i"> <text>the patient is in the second or third month of a grace period and review of a claim for reimbursement may be suspended; and</text> </level> <level label="ii"> <text>a carrier is not prohibited from denying a claim for reimbursement of a suspended claim; and</text> </level> </level> <level label="4"> <text>the carrier complies with the notice and claim payment requirements under § 15–1005 of this subtitle.</text> </level> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1010" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Adverse benefit determination” means:</text> <level label="i"> <text>a denial, reduction, or termination of a disability benefit;</text> </level> <level label="ii"> <text>a failure to provide or make payment, in whole or in part, for a disability benefit; or</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="3"> <level label="i"> <text>“Disability benefit” means a benefit that is payable based on the disability of a covered individual.</text> </level> <level label="ii"> <text>“Disability benefit” does not include:</text> <level label="1"> <text>long–term care insurance;</text> </level> <level label="2"> <text>a benefit that is payable based solely on a dismemberment of a covered individual;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>benefits in a health insurance policy that operate to safeguard the contract from lapse due to disability.</text> </level> </level> </level> </level> <level label="b"> <level label="1"> <text>The Commissioner shall adopt regulations that establish standards governing the processing of claims by an insurer that:</text> <level label="i"> <text>issues or delivers individual policies in the State that include a disability benefit; or</text> </level> <level label="ii"> <text>issues or delivers group policies in the State that include a disability benefit.</text> </level> </level> <level label="2"> <text>The regulations adopted under this subsection shall establish and maintain reasonable claims procedures governing the filing of disability benefit claims, including:</text> <level label="i"> <text>notification of an adverse benefit determination; and</text> </level> <level label="ii"> <text>an appeal by an insured or the insured’s authorized representative of an insurer’s adverse benefit determination.</text> </level> </level> <level label="3"> <text>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).</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1011" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review"> <level label="a"> <level label="1"> <text>This section applies to:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.</text> </level> </level> <level label="2"> <text>This section does not apply to claims for reimbursement:</text> <level label="i"> <text>for services received under Medicare supplemental policies or contracts; or</text> </level> <level label="ii"> <text>for pharmaceutical or vision services.</text> </level> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>by first–class mail; and</text> </level> <level label="2"> <text>at the election of the entity:</text> <level label="i"> <text>by facsimile transmission; or</text> </level> <level label="ii"> <text>through a Web site that allows for the secure transmission of information.</text> </level> </level> </level> <level label="c"> <text>An entity subject to this section annually shall provide:</text> <level label="1"> <text>a notice that a claims form may be submitted:</text> <level label="i"> <text>by first–class mail; and</text> </level> <level label="ii"> <text>at the election of the entity:</text> <level label="1"> <text>by facsimile transmission; or</text> </level> <level label="2"> <text>through a Web site that allows for the secure transmission of information; and</text> </level> </level> </level> <level label="2"> <text>instructions on how to submit a claim by facsimile transmission or through a secure Web site.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-01" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <level label="1"> <text>“Adverse decision” means:</text> <level label="i"> <text>a utilization review determination by a private review agent, a carrier, or a health care provider acting on behalf of a carrier that:</text> <level label="1"> <text>a proposed or delivered health care service covered under the member’s contract is or was not medically necessary, appropriate, or efficient; and</text> </level> <level label="2"> <text>may result in noncoverage of the health care service; or</text> </level> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>“Adverse decision” includes a utilization review determination based on a prior authorization or step therapy requirement.</text> </level> <level label="3"> <text>“Adverse decision” does not include a decision concerning a subscriber’s status as a member.</text> </level> </level> <level label="c"> <text>“Carrier” means a person that offers a health benefit plan and is:</text> <level label="1"> <text>an authorized insurer that provides health insurance in the State;</text> </level> <level label="2"> <text>a nonprofit health service plan;</text> </level> <level label="3"> <text>a health maintenance organization;</text> </level> <level label="4"> <text>a dental plan organization;</text> </level> <level label="5"> <text>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</text> </level> <level label="6"> <text>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.</text> </level> </level> <level label="d"> <text>“Complaint” means a protest filed with the Commissioner involving an adverse decision or grievance decision concerning the member.</text> </level> <level label="e"> <text>“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.</text> </level> <level label="f"> <text>“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.</text> </level> <level label="g"> <text>“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.</text> </level> <level label="h"> <text>“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.</text> </level> <level label="i"> <text>“Health benefit plan” has the meaning stated in § 2–112.2(a) of this article.</text> </level> <level label="j"> <text>“Health care provider” means:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>a hospital, as defined in § 19–301 of the Health – General Article.</text> </level> </level> <level label="k"> <text>“Health care service” means a health or medical care procedure or service rendered by a health care provider that:</text> <level label="1"> <text>provides testing, diagnosis, or treatment of a human disease or dysfunction;</text> </level> <level label="2"> <text>dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; or</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="l"> <level label="1"> <text>“Member” means a person entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by a carrier.</text> </level> <level label="2"> <text>“Member” includes:</text> <level label="i"> <text>a subscriber; and</text> </level> <level label="ii"> <text>unless preempted by federal law, a Medicare recipient.</text> </level> </level> <level label="3"> <text>“Member” does not include a Medicaid recipient.</text> </level> </level> <level label="m"> <text>“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.</text> </level> <level label="n"> <text>“Private review agent” has the meaning stated in § 15–10B–01 of this title.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-01.1" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <text>This subtitle applies to a health benefit plan that:</text> <level label="1"> <text>is delivered or issued in the State; or</text> </level> <level label="2"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-02" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <level label="a"> <text>Each carrier shall establish an internal grievance process for its members.</text> </level> <level label="b"> <level label="1"> <text>An internal grievance process shall meet the same requirements established under Subtitle 10B of this title.</text> </level> <level label="2"> <text>In addition to the requirements of Subtitle 10B of this title, an internal grievance process established by a carrier under this section shall:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>the grievance involves an emergency case under item (i) of this paragraph;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>the grievance involves a retrospective denial under item (iv) of this paragraph;</text> </level> </level> <level label="iii"> <text>allow a grievance to be filed on behalf of a member by a health care provider or the member’s representative;</text> </level> <level label="iv"> <text>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</text> </level> <level label="v"> <text>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.</text> </level> </level> <level label="3"> <text>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:</text> <level label="i"> <text>the adverse decision was rendered for health care services that are proposed but have not been provided; and</text> </level> <level label="ii"> <text>the services are necessary to treat a condition or illness that, without immediate medical attention, would:</text> <level label="1"> <text>seriously jeopardize the life or health of the member or the member’s ability to regain maximum functions;</text> </level> <level label="2"> <text>cause the member to be in danger to self or others; or</text> </level> <level label="3"> <text>cause the member to continue using intoxicating substances in an imminently dangerous manner.</text> </level> </level> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <level label="i"> <text>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:</text> <level label="1"> <text>the carrier waives the requirement that the carrier’s internal grievance process be exhausted before filing a complaint with the Commissioner;</text> </level> <level label="2"> <text>the carrier has failed to comply with any of the requirements of the internal grievance process as described in this section; or</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="e"> <text>Each carrier shall:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>file any revision to the internal grievance process with the Commissioner and the Health Advocacy Unit at least 30 days before its intended use.</text> </level> </level> <level label="f"> <level label="1"> <text>For nonemergency cases, when a carrier renders an adverse decision, the carrier shall:</text> <level label="i"> <text>inform the member, the member’s representative, or the health care provider acting on behalf of the member of the adverse decision:</text> <level label="1"> <text>orally by telephone; or</text> </level> <level label="2"> <text>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</text> </level> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>states at the top in prominent bold print:</text> </level> <level label="A"> <text>that the notice is a denial of a requested health care service;</text> </level> <level label="B"> <text>that the member may file an appeal;</text> </level> <level label="C"> <text>the telephone number and e–mail address required to be available under § 15–10B–05(e) of this title; and</text> </level> <level label="D"> <text>that the notice includes additional information on how to file and receive assistance for filing a complaint;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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:</text> </level> <level label="A"> <text>generalized terms such as “experimental procedure not covered”, “cosmetic procedure not covered”, “service included under another procedure”, or “not medically necessary”; or</text> </level> <level label="B"> <text>language directing the member to review the additional coverage criteria in the member’s policy or plan documents;</text> </level> <level label="4"> <text>includes a unique identifier for and the business address and business telephone number of:</text> </level> <level label="A"> <text>if the carrier is a health maintenance organization, the medical director or associate medical director, as appropriate, who made the decision; or</text> </level> <level label="B"> <text>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;</text> </level> <level label="5"> <text>gives written details of the carrier’s internal grievance process and procedures under this subtitle; and</text> </level> <level label="6"> <text>includes the following information:</text> </level> <level label="A"> <text>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;</text> </level> <level label="B"> <text>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;</text> </level> <level label="C"> <text>the Commissioner’s address, telephone number, and facsimile number;</text> </level> <level label="D"> <text>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</text> </level> <level label="E"> <text>the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.</text> </level> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="g"> <text>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:</text> <level label="1"> <text>after confirming through a complete review of any information already submitted by the health care provider:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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</text> </level> </level> <level label="2"> <text>assist the member, the member’s representative, or the health care provider in gathering the necessary information without further delay.</text> </level> </level> <level label="h"> <text>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.</text> </level> <level label="i"> <level label="1"> <text>For nonemergency cases, when a carrier renders a grievance decision, the carrier shall:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>states at the top in prominent bold print:</text> </level> <level label="A"> <text>that the notice is a denial of a requested health care service;</text> </level> <level label="B"> <text>that the member may file a complaint with the Commissioner;</text> </level> <level label="C"> <text>the telephone number and e–mail address required to be available under § 15–10B–05(e) of this title; and</text> </level> <level label="D"> <text>that the notice includes additional information on how to file and receive assistance for an appeal;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>includes a unique identifier for and the business address and business telephone number of:</text> </level> <level label="A"> <text>if the carrier is a health maintenance organization, the medical director or associate medical director, as appropriate, who made the grievance decision; or</text> </level> <level label="B"> <text>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</text> </level> <level label="5"> <text>includes the following information:</text> </level> <level label="A"> <text>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;</text> </level> <level label="B"> <text>the Commissioner’s address, telephone number, and facsimile number;</text> </level> <level label="C"> <text>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</text> </level> <level label="D"> <text>the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.</text> </level> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>To satisfy the requirements of this subsection, a carrier may not use solely in the written notice sent under paragraph (1) of this subsection:</text> <level label="i"> <text>generalized terms such as “experimental procedure not covered”, “cosmetic procedure not covered”, “service included under another procedure”, or “not medically necessary”; or</text> </level> <level label="ii"> <text>language directing the member to review the additional coverage criteria in the member’s policy or plan documents.</text> </level> </level> </level> <level label="j"> <level label="1"> <text>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:</text> <level label="i"> <text>the member and the member’s representative, if any; and</text> </level> <level label="ii"> <text>if the grievance was filed on behalf of the member under subsection (b)(2)(iii) of this section, the health care provider.</text> </level> </level> <level label="2"> <text>A notice required to be sent under paragraph (1) of this subsection shall include the following:</text> <level label="i"> <text>for an adverse decision, the information required under subsection (f) of this section; and</text> </level> <level label="ii"> <text>for a grievance decision, the information required under subsection (i) of this section.</text> </level> </level> </level> <level label="k"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="l"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>If a carrier delegates its internal grievance process to a private review agent, the carrier shall be:</text> <level label="i"> <text>bound by the grievance decision made by the private review agent acting on behalf of the carrier; and</text> </level> <level label="ii"> <text>responsible for a violation of any provision of this subtitle regardless of the delegation made by the carrier under paragraph (1) of this subsection.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-03" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="b"> <level label="1"> <text>In developing procedures to be used in reviewing and deciding complaints, the Commissioner shall:</text> <level label="i"> <text>allow a health care provider to file a complaint on behalf of a member; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <text>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:</text> <level label="i"> <text>within 45 days after a complaint regarding a pending health care service is filed; and</text> </level> <level label="ii"> <text>within 45 days after a complaint is filed regarding a retrospective denial of services already provided.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the Commissioner has not yet received information requested by the Commissioner; and</text> </level> <level label="ii"> <text>the information requested is necessary for the Commissioner to render a final decision on the complaint.</text> </level> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>A carrier shall have the burden of persuasion that its adverse decision or grievance decision, as applicable, is correct:</text> <level label="i"> <text>during the review of a complaint by the Commissioner or a designee of the Commissioner; and</text> </level> <level label="ii"> <text>in any hearing held in accordance with § 2–210 of this article.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> <level label="iii"> <text>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.</text> </level> <level label="iv"> <text>The Commissioner’s use of additional information may not delay the Commissioner’s decision on the complaint by more than 5 working days.</text> </level> </level> </level> <level label="f"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-04" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <level label="a"> <text>The Commissioner shall:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The Commissioner shall include in the notice the information required under subsection (a)(3) of this section.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>issue an administrative order that requires the carrier to:</text> <level label="1"> <text>cease inappropriate conduct or practices by the carrier or any of the personnel employed or associated with the carrier;</text> </level> <level label="2"> <text>fulfill the carrier’s contractual obligations;</text> </level> <level label="3"> <text>provide a health care service or payment that has been denied improperly; or</text> </level> <level label="4"> <text>take appropriate steps to restore the carrier’s ability to provide a health care service or payment that is provided under a contract; or</text> </level> </level> <level label="ii"> <text>impose any penalty or fine or take any action as authorized:</text> <level label="1"> <text>for an insurer, nonprofit health service plan, or dental plan organization, under this article; or</text> </level> <level label="2"> <text>for a health maintenance organization, under the Health – General Article or under this article.</text> </level> </level> </level> <level label="3"> <text>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.</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>A final decision of the Commissioner made on a complaint under this subtitle:</text> <level label="i"> <text>is not subject to a request for a hearing under this subtitle for a carrier; and</text> </level> <level label="ii"> <text>is subject to a right to file a petition for judicial review under § 2–215 of this article for a carrier or a member.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-05" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <level label="a"> <text>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:</text> <level label="1"> <text>shall select an independent review organization or medical expert to advise on the complaint; and</text> </level> <level label="2"> <text>may accept and base the final decision on the complaint on the professional judgment of an independent review organization or medical expert.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>hold:</text> <level label="i"> <text>a nonrestricted license in a state of the United States; and</text> </level> <level label="ii"> <text>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</text> </level> </level> <level label="3"> <text>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.</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>the names of all holders of bonds or notes in excess of $100,000, if any;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>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</text> </level> <level label="5"> <text>evidence, in the form required by the Commissioner, that the independent review organization is accredited by a nationally recognized private accrediting organization.</text> </level> </level> <level label="f"> <text>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:</text> <level label="1"> <text>the carrier that is the subject of the complaint;</text> </level> <level label="2"> <text>any officer, director, or management employee of the carrier that is the subject of the complaint;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>the health care facility at which the health care service was provided or will be provided; or</text> </level> <level label="5"> <text>the developer or manufacturer of the principal drug, device, procedure, or other therapy that is being proposed for the member.</text> </level> </level> <level label="g"> <text>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:</text> <level label="1"> <text>the timeliness and quality of the reviews;</text> </level> <level label="2"> <text>the qualifications and independence of the expert reviewers; and</text> </level> <level label="3"> <text>the confidentiality of medical records and review materials.</text> </level> </level> <level label="h"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The independent review organization or medical expert shall:</text> <level label="i"> <text>present to the carrier for payment a detailed account of the expenses incurred by the independent review organization or medical expert; and</text> </level> <level label="ii"> <text>provide a copy of the detailed account of expenses to the Commissioner.</text> </level> </level> <level label="3"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-06" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <level label="a"> <level label="1"> <text>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:</text> <level label="i"> <text>the number of members entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by the carrier;</text> </level> <level label="ii"> <text>the number of clean claims for reimbursement processed by the carrier;</text> </level> <level label="iii"> <text>the activities of the carrier under this subtitle, including:</text> <level label="1"> <text>the outcome of each grievance filed with the carrier;</text> </level> <level label="2"> <text>the number and outcomes of cases that were considered emergency cases under § 15–10A–02(b)(2)(i) of this subtitle;</text> </level> <level label="3"> <text>the time within which the carrier made a grievance decision on each emergency case;</text> </level> <level label="4"> <text>the time within which the carrier made a grievance decision on all other cases that were not considered emergency cases;</text> </level> <level label="5"> <text>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;</text> </level> <level label="6"> <text>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;</text> </level> <level label="7"> <text>the number of adverse decisions overturned after a reconsideration request under § 15–10B–06 of this title; and</text> </level> <level label="8"> <text>the number of requests made and granted under § 15–831(c)(1) and (2) of this title; and</text> </level> </level> <level label="iv"> <text>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.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>a description of any changes in medical management contributing to the rise in adverse decisions for the type of service;</text> </level> <level label="ii"> <text>any other known reasons for the increase; and</text> </level> <level label="iii"> <text>a description of the carrier’s efforts and actions taken to determine the reason for the increase.</text> </level> </level> </level> <level label="b"> <text>The Commissioner shall:</text> <level label="1"> <text>compile an annual summary report based on the information provided:</text> <level label="i"> <text>under subsection (a) of this section; and</text> </level> <level label="ii"> <text>by the Secretary under § 19–705.2(e) of the Health – General Article;</text> </level> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>report any violations or actions taken under § 15–10B–11 of this title; and</text> </level> <level label="4"> <text>provide copies of the summary report to the Governor and, subject to § 2–1257 of the State Government Article, to the General Assembly.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-07" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <text>On a quarterly basis, the Health Advocacy Unit shall submit a report to the Commissioner that:</text> <level label="1"> <text>describes activities it performed on behalf of members that have participated in an internal grievance process of a carrier established under this subtitle;</text> </level> <level label="2"> <text>describes its efforts to mediate cases that involve an adverse decision;</text> </level> <level label="3"> <text>names each carrier involved in the cases described in the report;</text> </level> <level label="4"> <text>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</text> </level> <level label="5"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-08" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <level label="a"> <text>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.</text> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>In consultation with the Commissioner and any affected State government agency or unit, the Health Advocacy Unit shall:</text> <level label="i"> <text>evaluate the effectiveness of the internal grievance process and complaint process available to members; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-09" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <level label="a"> <text>The Commissioner shall adopt regulations to carry out this subtitle.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>access the Consumer Education and Advocacy Program in the Administration.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10A-10" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-10B-01" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <level label="1"> <text>“Adverse decision” means a utilization review determination made by a private review agent that a proposed or delivered health care service:</text> <level label="i"> <text>is or was not medically necessary, appropriate, or efficient; and</text> </level> <level label="ii"> <text>may result in noncoverage of the health care service.</text> </level> </level> <level label="2"> <text>“Adverse decision” includes a utilization review determination based on a prior authorization or step therapy requirement.</text> </level> <level label="3"> <text>“Adverse decision” does not include a decision concerning a subscriber’s status as a member.</text> </level> </level> <level label="c"> <text>“Certificate” means a certificate of registration granted by the Commissioner to a private review agent.</text> </level> <level label="d"> <level label="1"> <text>“Employee assistance program” means a health care service plan that, in accordance with a contract with an employer or labor union:</text> <level label="i"> <text>consults with employees or members of an employee’s family or both to:</text> <level label="1"> <text>identify the employee’s or the employee’s family member’s mental health, alcohol, or substance abuse problems; and</text> </level> <level label="2"> <text>refer the employee or the employee’s family member to health care providers or other community resources for counseling, therapy, or treatment; and</text> </level> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>“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.</text> </level> </level> <level label="e"> <level label="1"> <text>“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.</text> </level> <level label="2"> <text>“Grievance” does not include a verbal request for reconsideration of a utilization review determination.</text> </level> </level> <level label="f"> <text>“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.</text> </level> <level label="g"> <text>“Health care facility” means:</text> <level label="1"> <text>a hospital as defined in § 19–301 of the Health – General Article;</text> </level> <level label="2"> <text>a related institution as defined in § 19–301 of the Health – General Article;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>a facility that is organized primarily to help in the rehabilitation of disabled individuals;</text> </level> <level label="5"> <text>a home health agency as defined in § 19–401 of the Health – General Article;</text> </level> <level label="6"> <text>a hospice as defined in § 19–901 of the Health – General Article;</text> </level> <level label="7"> <text>a facility that provides radiological or other diagnostic imagery services;</text> </level> <level label="8"> <text>a medical laboratory as defined in § 17–201 of the Health – General Article; or</text> </level> <level label="9"> <text>an alcohol abuse and drug abuse treatment program as defined in § 8–403 of the Health – General Article.</text> </level> </level> <level label="h"> <text>“Health care provider” means:</text> <level label="1"> <text>an individual who:</text> <level label="i"> <text>is licensed or otherwise authorized to provide health care services in the ordinary course of business or practice of a profession; and</text> </level> <level label="ii"> <text>is a treating provider of a patient; or</text> </level> </level> <level label="2"> <text>a hospital, as defined in § 19–301 of the Health – General Article.</text> </level> </level> <level label="i"> <text>“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:</text> <level label="1"> <text>provides testing, diagnosis, or treatment of a human disease or dysfunction;</text> </level> <level label="2"> <text>dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; or</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="j"> <text>“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.</text> </level> <level label="k"> <text>“Private review agent” means:</text> <level label="1"> <text>a nonhospital–affiliated person or entity performing utilization review that is either affiliated with, under contract with, or acting on behalf of:</text> <level label="i"> <text>a Maryland business entity; or</text> </level> <level label="ii"> <text>a third party that pays for, provides, or administers health care services to citizens of this State; or</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the hospital; or</text> </level> <level label="ii"> <text>a business wholly owned by the hospital.</text> </level> </level> </level> <level label="l"> <text>“Significant beneficial interest” means the ownership of any financial interest that is greater than the lesser of:</text> <level label="1"> <text>5 percent of the whole; or</text> </level> <level label="2"> <text>$5,000.</text> </level> </level> <level label="m"> <text>“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.</text> </level> <level label="n"> <text>“Utilization review plan” means a description of the standards governing utilization review activities performed by a private review agent.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-02" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <text>The purpose of this subtitle is to:</text> <level label="1"> <text>promote the delivery of quality health care in a cost effective manner that ensures timely access to health care services;</text> </level> <level label="2"> <text>foster greater coordination, communication, and transparency between payors, patients, and providers conducting utilization review activities;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>ensure that private review agents maintain the confidentiality of medical records in accordance with applicable State and federal laws.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-03" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>A private review agent may not conduct utilization review in this State unless the Commissioner has granted the private review agent a certificate.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>A certificate issued under this subtitle is not transferable.</text> </level> <level label="d"> <text>The Commissioner may consider an applicant as having met a particular certification requirement under this subtitle if:</text> <level label="1"> <text>the applicant has obtained utilization management accreditation from an approved accrediting organization as determined by the Commissioner;</text> </level> <level label="2"> <text>the approved accrediting organization has requirements that meet or exceed the particular requirement in this subtitle; and</text> </level> <level label="3"> <text>the applicant demonstrates that the applicant meets or exceeds the particular requirement under this subtitle.</text> </level> </level> <level label="e"> <text>The Commissioner may adopt regulations to implement the provisions of this section.</text> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <level label="1"> <text>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.</text> </level> <level label="2"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>The uniform treatment plan form adopted by the Commissioner:</text> <level label="1"> <text>shall adequately protect the confidentiality of the patient; and</text> </level> <level label="2"> <text>may only request the patient’s membership number, policy number, or other similar unique patient identifier and first name for patient identification.</text> </level> </level> <level label="iii"> <text>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.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-04" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>An applicant for a certificate shall:</text> <level label="1"> <text>submit an application to the Commissioner; and</text> </level> <level label="2"> <text>pay to the Commissioner the application fee established by the Commissioner through regulation.</text> </level> </level> <level label="b"> <text>The application shall:</text> <level label="1"> <text>be on a form and accompanied by any supporting documentation that the Commissioner requires; and</text> </level> <level label="2"> <text>be signed and verified by the applicant.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-05" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>In conjunction with the application, the private review agent shall submit information that the Commissioner requires including:</text> <level label="1"> <text>a utilization review plan that includes:</text> <level label="i"> <text>the specific criteria and standards to be used in conducting utilization review of proposed or delivered health care services;</text> </level> <level label="ii"> <text>those circumstances, if any, under which utilization review may be delegated to a hospital utilization review program; and</text> </level> <level label="iii"> <text>if applicable, any provisions by which patients or physicians, hospitals, or other health care providers may seek reconsideration;</text> </level> </level> <level label="2"> <text>the type and qualifications of the personnel either employed or under contract to perform the utilization review;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>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;</text> </level> <level label="5"> <text>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;</text> </level> <level label="6"> <text>the policies and procedures to ensure that all applicable State and federal laws to protect the confidentiality of individual medical records are followed;</text> </level> <level label="7"> <text>a copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan;</text> </level> <level label="8"> <text>a list of the third party payors for which the private review agent is performing utilization review in this State;</text> </level> <level label="9"> <text>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;</text> </level> <level label="10"> <text>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</text> </level> <level label="11"> <text>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:</text> <level label="i"> <text>objective;</text> </level> <level label="ii"> <text>clinically valid;</text> </level> <level label="iii"> <text>reflected in published peer–reviewed scientific studies and medical literature;</text> </level> <level label="iv"> <text>developed by:</text> <level label="1"> <text>a nonprofit health care provider professional medical or clinical specialty society, including through the use of patient placement criteria and clinical practice guidelines; or</text> </level> <level label="2"> <text>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:</text> </level> <level label="A"> <text>does not receive direct payments based on the outcome of the utilization review; and</text> </level> <level label="B"> <text>demonstrates that its clinical criteria are consistent with criteria and standards generally recognized by health care providers practicing in the relevant clinical specialties;</text> </level> </level> <level label="v"> <text>recommended by federal agencies;</text> </level> <level label="vi"> <text>approved by the federal Food and Drug Administration as part of drug labeling;</text> </level> <level label="vii"> <text>taking into account the needs of atypical patient populations and diagnoses, including the unique needs of children and adolescents;</text> </level> <level label="viii"> <text>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;</text> </level> <level label="ix"> <text>ensuring quality of care of health care services;</text> </level> <level label="x"> <text>reviewed, evaluated, and updated at least annually and as necessary to reflect any changes; and</text> </level> <level label="xi"> <text>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.</text> </level> </level> </level> <level label="b"> <text>The private review agent shall:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>A private review agent shall advise the Commissioner, in writing, of a change in:</text> <level label="1"> <text>ownership, medical director, or chief executive officer within 30 days of the date of the change;</text> </level> <level label="2"> <text>the name, address, or telephone number of the private review agent within 30 days of the date of the change; or</text> </level> <level label="3"> <text>the private review agent’s scope of responsibility under a contract.</text> </level> </level> <level label="e"> <level label="1"> <text>A private review agent shall:</text> <level label="i"> <text>have available the following dedicated to utilization review:</text> <level label="1"> <text>a direct telephone number that is not the general customer call number; and</text> </level> <level label="2"> <text>a monitored e–mail address; and</text> </level> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-05.1" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization;</text> </level> <level label="iv"> <text>a dental plan organization; or</text> </level> <level label="v"> <text>any other person that provides health benefit plans subject to regulation by the State.</text> </level> </level> </level> <level label="b"> <text>This section applies to:</text> <level label="1"> <text>a carrier that:</text> <level label="i"> <text>uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review; or</text> </level> <level label="ii"> <text>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</text> </level> </level> <level label="2"> <text>a pharmacy benefits manager or private review agent that:</text> <level label="i"> <text>contracts with a carrier to provide utilization review on behalf of the carrier; and</text> </level> <level label="ii"> <text>uses an artificial intelligence, algorithm, or other software tool for the purpose of conducting utilization review on behalf of the carrier.</text> </level> </level> </level> <level label="c"> <text>Subject to subsection (d) of this section, an entity subject to this section shall ensure that:</text> <level label="1"> <text>an artificial intelligence, algorithm, or other software tool bases its determinations on:</text> <level label="i"> <text>an enrollee’s medical or other clinical history;</text> </level> <level label="ii"> <text>individual clinical circumstances as presented by a requesting provider; or</text> </level> <level label="iii"> <text>other relevant clinical information contained in the enrollee’s medical or other clinical record;</text> </level> </level> <level label="2"> <text>an artificial intelligence, algorithm, or other software tool does not base its determinations solely on a group dataset;</text> </level> <level label="3"> <text>the criteria and guidelines for using an artificial intelligence, algorithm, or other software tool for making determinations comply with the requirements of this title;</text> </level> <level label="4"> <text>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;</text> </level> <level label="5"> <text>the use of an artificial intelligence, algorithm, or other software tool does not result in unfair discrimination;</text> </level> <level label="6"> <text>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;</text> </level> <level label="7"> <text>an artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the Commissioner;</text> </level> <level label="8"> <text>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;</text> </level> <level label="9"> <text>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;</text> </level> <level label="10"> <text>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</text> </level> <level label="11"> <text>an artificial intelligence, algorithm, or other software tool does not directly or indirectly cause harm to an enrollee.</text> </level> </level> <level label="d"> <text>An artificial intelligence, algorithm, or other software tool may not deny, delay, or modify health care services.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-06" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <level label="1"> <text>Except as otherwise provided in this subsection, a private review agent shall:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>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</text> </level> <level label="iv"> <text>promptly notify the health care provider of the determination.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the information, including any lab or diagnostic test or other medical information, that must be submitted to complete the request; and</text> </level> <level label="ii"> <text>the criteria and standards to support the need for additional information.</text> </level> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>if additional information is needed, promptly request the specific information needed, including any lab or diagnostic test or other medical information; and</text> </level> <level label="3"> <text>promptly notify the health care provider of the determination.</text> </level> </level> <level label="c"> <level label="1"> <text>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:</text> <level label="i"> <text>in real time if:</text> <level label="1"> <text>no additional information is needed by the private review agent to process the request; and</text> </level> <level label="2"> <text>the request meets the private review agent’s criteria for approval; or</text> </level> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the information, including any lab or diagnostic test or other medical information, that must be submitted to complete the request; and</text> </level> <level label="ii"> <text>the criteria and standards to support the need for the additional information.</text> </level> </level> </level> <level label="d"> <level label="1"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>promptly request the specific information needed, including any lab or diagnostic test or other medical information; and</text> </level> <level label="2"> <text>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.</text> </level> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>seriously jeopardize the life or health of the member or the member’s ability to regain maximum functions;</text> </level> <level label="ii"> <text>cause the member to be in danger to self or others; or</text> </level> <level label="iii"> <text>cause the member to continue using intoxicating substances in an imminently dangerous manner.</text> </level> </level> </level> <level label="e"> <text>If a private review agent fails to make a determination within the time limits required under this section, the request shall be deemed approved.</text> </level> <level label="f"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>a direct telephone number that is not the general customer call number; or</text> </level> <level label="ii"> <text>a monitored e–mail address that is dedicated to communication related to utilization review.</text> </level> </level> </level> <level label="g"> <text>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:</text> <level label="1"> <text>the patient’s insurance status; and</text> </level> <level label="2"> <text>if applicable, the private review agent’s emergency admission notification requirements.</text> </level> </level> <level label="h"> <level label="1"> <text>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:</text> <level label="i"> <text>the admission is based on a determination that the patient is in imminent danger to self or others;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>the hospital immediately notifies the private review agent of:</text> <level label="1"> <text>the admission of the patient; and</text> </level> <level label="2"> <text>the reasons for the admission.</text> </level> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the admission is an involuntary admission under §§ 10–615 and 10–617(a) of the Health – General Article; and</text> </level> <level label="ii"> <text>the hospital immediately notifies the private review agent of:</text> <level label="1"> <text>the admission of the patient; and</text> </level> <level label="2"> <text>the reasons for the admission.</text> </level> </level> </level> </level> <level label="i"> <level label="1"> <text>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:</text> <level label="i"> <text>shall accept:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>if a service was provided in another state, a treatment plan form mandated by the state in which the service was provided; and</text> </level> </level> <level label="ii"> <text>may not impose any requirement to:</text> <level label="1"> <text>modify the uniform treatment plan form or its content; or</text> </level> <level label="2"> <text>submit additional treatment plan forms.</text> </level> </level> </level> <level label="2"> <text>A uniform treatment plan form submitted under the provisions of this subsection:</text> <level label="i"> <text>shall be properly completed by the health care provider; and</text> </level> <level label="ii"> <text>may be submitted by electronic transfer.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-07" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <level label="1"> <text>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:</text> <level label="i"> <text>board certified or eligible in the same specialty as the treatment under review; and</text> </level> <level label="ii"> <text>knowledgeable about the requested health care service or treatment through actual clinical experience.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>is board certified or eligible in the same specialty as the treatment under review; or</text> </level> <level label="ii"> <text>is actively practicing or has demonstrated expertise in the substance abuse or mental health service or treatment under review.</text> </level> </level> <level label="3"> <text>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.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>A private review agent may retrospectively render an adverse decision regarding preauthorized or approved services delivered to a patient if:</text> <level label="1"> <text>the information submitted to the private review agent regarding the services to be delivered to the patient was fraudulent or intentionally misrepresentative;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>the planned course of treatment for the patient that was approved by the private review agent was not substantially followed by the provider.</text> </level> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-08" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>A private review agent may not charge a fee to a patient or health care provider for filing a grievance.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-09" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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:</text> <level label="1"> <text>48 hours of inpatient hospitalization care following an uncomplicated vaginal delivery; and</text> </level> <level label="2"> <text>96 hours of inpatient hospitalization care following an uncomplicated cesarean section.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>one home visit scheduled to occur within 24 hours after hospital discharge; and</text> </level> <level label="ii"> <text>an additional home visit as may be prescribed by the attending provider.</text> </level> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>A home visit under paragraph (2) or (3) of this subsection shall:</text> <level label="i"> <text>be provided in accordance with generally accepted standards of nursing practice for home care of a mother and newborn child;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>include any services required by the attending provider.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-09.1" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <text>A grievance decision shall be made based on the professional judgment of:</text> <level label="1"> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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;</text> </level> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>when the grievance decision involves a mental health or substance abuse service:</text> <level label="i"> <text>a licensed physician who:</text> <level label="1"> <text>is board certified or eligible in the same specialty as the treatment under review; or</text> </level> <level label="2"> <text>is actively practicing or has demonstrated expertise in the substance abuse or mental health service or treatment under review; or</text> </level> </level> <level label="ii"> <text>a panel of other appropriate health care service reviewers with at least one licensed physician, selected by the private review agent who:</text> <level label="1"> <text>is board certified or eligible in the same specialty as the treatment under review; or</text> </level> <level label="2"> <text>is actively practicing or has demonstrated expertise in the substance abuse or mental health service or treatment under review.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-10" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>Before the certificate expires, a certificate may be renewed for an additional 2-year term if the applicant:</text> <level label="1"> <text>otherwise is entitled to the certificate;</text> </level> <level label="2"> <text>pays to the Commissioner the renewal fee set by the Commissioner through regulation; and</text> </level> <level label="3"> <text>submits to the Commissioner:</text> <level label="i"> <text>a renewal application on the form that the Commissioner requires; and</text> </level> <level label="ii"> <text>satisfactory evidence of compliance with any requirement under this subtitle for certificate renewal.</text> </level> </level> </level> <level label="c"> <text>If the requirements of this section are met, the Commissioner shall renew a certificate.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-11" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <text>A private review agent may not:</text> <level label="1"> <text>violate any provision of this subtitle or any rule or regulation adopted under this subtitle;</text> </level> <level label="2"> <text>fail to meet the requirements for certification under this subtitle;</text> </level> <level label="3"> <text>obtain or attempt to obtain certification based on inaccurate information;</text> </level> <level label="4"> <text>fraudulently or deceptively obtain or use a certificate;</text> </level> <level label="5"> <text>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;</text> </level> <level label="6"> <text>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;</text> </level> <level label="7"> <text>fail to protect the confidentiality of medical records in accordance with applicable State and federal laws;</text> </level> <level label="8"> <text>use criteria and standards to conduct utilization review unless the criteria and standards used by the private review agent are:</text> <level label="i"> <text>objective;</text> </level> <level label="ii"> <text>clinically valid;</text> </level> <level label="iii"> <text>compatible with established principles of health care; or</text> </level> <level label="iv"> <text>flexible enough to allow deviations from norms when justified on a case-by-case basis; or</text> </level> </level> <level label="9"> <text>act as a private review agent without holding a certificate issued under this subtitle.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-12" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>Each day a violation is continued after the first conviction is a separate offense.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>deny, suspend, or revoke the certificate to do business as a private review agent;</text> </level> <level label="2"> <text>issue an order to cease and desist from acting as a private review agent without holding a certificate issued under this subtitle;</text> </level> <level label="3"> <text>require a private review agent to make restitution to a patient who has suffered actual economic damage because of the violation; and</text> </level> <level label="4"> <text>impose an administrative penalty of up to $5,000 for each violation of any provision of this subtitle.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-13" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-10B-14" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-10B-15" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-10B-16" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <text>The Commissioner may establish reporting requirements to:</text> <level label="1"> <text>evaluate the effectiveness of private review agents; and</text> </level> <level label="2"> <text>determine if the utilization review programs are in compliance with the provisions of this section and applicable regulations.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-17" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <level label="1"> <text>Except as provided in paragraph (2) of this subsection, this section does not apply to:</text> <level label="i"> <text>a private review agent referring an individual to a health care provider or facility that participates in a health maintenance organization;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>refer a patient who has undergone utilization review by the private review agent to:</text> <level label="i"> <text>a health care facility in which the private review agent owns a significant beneficial interest; or</text> </level> <level label="ii"> <text>the private review agent’s own health care practice;</text> </level> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <level label="i"> <text>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</text> </level> <level label="ii"> <text>the patient has no attending physician; and</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-18" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>A private review agent shall submit its certificate to the administration within 30 days after the date that the private review agent ceased operations.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-19" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>The examination shall be conducted in accordance with § 2-207 of this article.</text> </level> <level label="d"> <text>The expense of the examination shall be paid in accordance with § 2-208 of this article.</text> </level> <level label="e"> <text>The reports of the examination and investigation shall be issued in accordance with § 2-209 of this article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-20" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>The examination shall be conducted:</text> <level label="1"> <text>in accordance with § 2-207 of this article; and</text> </level> <level label="2"> <text>at least once every 3 years.</text> </level> </level> <level label="c"> <text>The expense of the examination shall be paid in accordance with § 2-208 of this article.</text> </level> <level label="d"> <text>The reports of the examination shall be issued in accordance with § 2-209 of this article.</text> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10B-21" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <level label="1"> <text>The Commissioner may have an adverse decision or grievance decision described under subsection (a) of this section reviewed by an independent review organization.</text> </level> <level label="2"> <text>The costs of a review conducted under paragraph (1) of this subsection shall be paid by the carrier.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10C-01" title_number="15" title_name="Health Insurance" subtitle_number="10C" subtitle_name="Medical Directors"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“Board” means the State Board of Physicians established under Title 14 of the Health Occupations Article.</text> </level> <level label="c"> <text>“Certificate” means a certificate issued by the Commissioner under this subtitle to act as a medical director.</text> </level> <level label="d"> <text>“Department” means the Maryland Department of Health.</text> </level> <level label="e"> <text>“Health maintenance organization” has the meaning stated in § 19–701 of the Health – General Article.</text> </level> <level label="f"> <level label="1"> <text>“Medical director” means a physician employed by or under contract with a health maintenance organization who is responsible for:</text> <level label="i"> <text>the establishment or maintenance of the policies and procedures at the health maintenance organization for:</text> <level label="1"> <text>quality assurance; and</text> </level> <level label="2"> <text>utilization management;</text> </level> </level> <level label="ii"> <text>compliance with the quality assurance and utilization management policies and procedures of the health maintenance organization; and</text> </level> <level label="iii"> <text>oversight of utilization review decisions of private review agents employed by or under contract with the health maintenance organization.</text> </level> </level> <level label="2"> <text>“Medical director” includes an associate medical director or an assistant medical director, as defined by the Commissioner by regulation.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10C-02" title_number="15" title_name="Health Insurance" subtitle_number="10C" subtitle_name="Medical Directors"> <text>The Commissioner, in consultation with the Department and the Board, shall establish and adopt by regulation standards for:</text> <level label="1"> <text>the certification of medical directors;</text> </level> <level label="2"> <text>the renewal, suspension, and revocation of a certificate; and</text> </level> <level label="3"> <text>the issuance of a temporary certificate.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10C-03" title_number="15" title_name="Health Insurance" subtitle_number="10C" subtitle_name="Medical Directors"> <level label="a"> <text>To be certified as a medical director under this subtitle, an applicant shall:</text> <level label="1"> <text>submit an application to the Commissioner on the form required by the Commissioner; and</text> </level> <level label="2"> <text>pay to the Commissioner an application fee of no more than $100 established by the Commissioner by regulation.</text> </level> </level> <level label="b"> <text>The application shall include:</text> <level label="1"> <text>a description of the applicant’s professional qualifications, including medical education information and, if appropriate, board certifications and licensure status;</text> </level> <level label="2"> <text>the utilization management procedures and policies to be used by the health maintenance organization; and</text> </level> <level label="3"> <text>certification by the medical director that the utilization management procedures and policies are:</text> <level label="i"> <text>objective;</text> </level> <level label="ii"> <text>clinically valid;</text> </level> <level label="iii"> <text>compatible with established principles of health care; and</text> </level> <level label="iv"> <text>flexible enough to allow deviations from the norms when justified on a case by case basis.</text> </level> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10C-04" title_number="15" title_name="Health Insurance" subtitle_number="10C" subtitle_name="Medical Directors"> <level label="a"> <text>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:</text> <level label="1"> <text>objective;</text> </level> <level label="2"> <text>clinically valid;</text> </level> <level label="3"> <text>compatible with established principles of health care; or</text> </level> <level label="4"> <text>flexible enough to allow deviations from the norms when justified on a case by case basis.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10D-01" title_number="15" title_name="Health Insurance" subtitle_number="10D" subtitle_name="Complaint Process for Coverage Decisions"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“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.</text> </level> <level label="c"> <text>“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.</text> </level> <level label="d"> <text>“Carrier” means a person that offers a health benefit plan and is:</text> <level label="1"> <text>an authorized insurer that provides health insurance in the State;</text> </level> <level label="2"> <text>a nonprofit health service plan;</text> </level> <level label="3"> <text>a health maintenance organization;</text> </level> <level label="4"> <text>a dental plan organization;</text> </level> <level label="5"> <text>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</text> </level> <level label="6"> <text>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.</text> </level> </level> <level label="e"> <text>“Complaint” means a protest filed with the Commissioner involving a coverage decision other than that which is covered by Subtitle 10A of this title.</text> </level> <level label="f"> <level label="1"> <text>“Coverage decision” means:</text> <level label="i"> <text>an initial determination by a carrier or a representative of the carrier that results in noncoverage of a health care service;</text> </level> <level label="ii"> <text>a determination by a carrier that an individual is not eligible for coverage under the carrier’s health benefit plan; or</text> </level> <level label="iii"> <text>any determination by a carrier that results in the rescission of an individual’s coverage under a health benefit plan.</text> </level> </level> <level label="2"> <text>“Coverage decision” includes nonpayment of all or any part of a claim.</text> </level> <level label="3"> <text>“Coverage decision” does not include:</text> <level label="i"> <text>an adverse decision as defined in § 15–10A–01(b) of this title; or</text> </level> <level label="ii"> <text>a pharmacy inquiry.</text> </level> </level> </level> <level label="g"> <text>“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.</text> </level> <level label="h"> <level label="1"> <text>“Health benefit plan” means:</text> <level label="i"> <text>a hospital or medical policy or contract, including a policy or contract issued under a multiple employer trust or association;</text> </level> <level label="ii"> <text>a hospital or medical policy or contract issued by a nonprofit health service plan;</text> </level> <level label="iii"> <text>a health maintenance organization contract; or</text> </level> <level label="iv"> <text>a dental plan organization contract.</text> </level> </level> <level label="2"> <text>“Health benefit plan” does not include one or more, or any combination of the following:</text> <level label="i"> <text>long–term care insurance;</text> </level> <level label="ii"> <text>disability insurance;</text> </level> <level label="iii"> <text>accidental travel and accidental death and dismemberment insurance;</text> </level> <level label="iv"> <text>credit health insurance;</text> </level> <level label="v"> <text>a health benefit plan issued by a managed care organization, as defined in Title 15, Subtitle 1 of the Health – General Article;</text> </level> <level label="vi"> <text>disease–specific insurance; or</text> </level> <level label="vii"> <text>fixed indemnity insurance.</text> </level> </level> </level> <level label="i"> <text>“Health care provider” means:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>a hospital, as defined in § 19–301 of the Health – General Article.</text> </level> </level> <level label="j"> <text>“Health care service” means a health or medical care procedure or service rendered by a health care provider that:</text> <level label="1"> <text>provides testing, diagnosis, or treatment of a human disease or dysfunction; or</text> </level> <level label="2"> <text>dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction.</text> </level> </level> <level label="k"> <level label="1"> <text>“Member” means:</text> <level label="i"> <text>a person entitled to health care services under a policy, plan, or contract issued or delivered in the State by a carrier; or</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>“Member” includes:</text> <level label="i"> <text>a subscriber; and</text> </level> <level label="ii"> <text>unless preempted by federal law, a Medicare recipient.</text> </level> </level> <level label="3"> <text>“Member” does not include a Medicaid recipient.</text> </level> </level> <level label="l"> <text>“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.</text> </level> <level label="m"> <text>“Pharmacy benefits manager” has the meaning stated in § 15–1601 of this title.</text> </level> <level label="n"> <text>“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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-10D-02" title_number="15" title_name="Health Insurance" subtitle_number="10D" subtitle_name="Complaint Process for Coverage Decisions"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>Notice of the coverage decision required to be sent under paragraph (1) of this subsection shall:</text> <level label="i"> <text>state in detail in clear, understandable language, the specific factual bases for the carrier’s decision; and</text> </level> <level label="ii"> <text>include the following information:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>the Commissioner’s address, telephone number, and facsimile number;</text> </level> <level label="4"> <text>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</text> </level> <level label="5"> <text>the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.</text> </level> </level> </level> </level> <level label="f"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>Notice of the appeal decision required to be sent under paragraph (1) of this subsection shall:</text> <level label="i"> <text>state in detail in clear, understandable language the specific factual bases for the carrier’s decision; and</text> </level> <level label="ii"> <text>include the following information:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>the Commissioner’s address, telephone number, and facsimile number;</text> </level> <level label="3"> <text>a statement that the Health Advocacy Unit is available to assist the member in filing a complaint with the Commissioner; and</text> </level> <level label="4"> <text>the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.</text> </level> </level> </level> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <level label="1"> <text>A carrier shall have the burden of persuasion that its coverage decision or appeal decision, as applicable, is correct:</text> <level label="i"> <text>during the review of a complaint by the Commissioner or a designee of the Commissioner; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="i"> <text>The Commissioner shall:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10D-03" title_number="15" title_name="Health Insurance" subtitle_number="10D" subtitle_name="Complaint Process for Coverage Decisions"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>issue an administrative order that requires the carrier to:</text> <level label="i"> <text>cease inappropriate conduct or practices by the carrier or any of the personnel employed or associated with the carrier;</text> </level> <level label="ii"> <text>fulfill the carrier’s contractual obligations;</text> </level> <level label="iii"> <text>provide a health care service or payment that has been denied improperly; or</text> </level> <level label="iv"> <text>take appropriate steps to restore the carrier’s ability to provide a health care service or payment that is provided under a contract; or</text> </level> </level> <level label="2"> <text>impose any penalty or fine or take any action as authorized:</text> <level label="i"> <text>for an insurer, nonprofit health service plan, or dental plan organization, under this article; or</text> </level> <level label="ii"> <text>for a health maintenance organization, under the Health - General Article or under this article.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-10D-04" title_number="15" title_name="Health Insurance" subtitle_number="10D" subtitle_name="Complaint Process for Coverage Decisions"> <text>The Commissioner may adopt any necessary regulations to carry out the provisions of this subtitle.</text> </section> <section article="gin" article_name="Insurance" number="15-10D-05" title_number="15" title_name="Health Insurance" subtitle_number="10D" subtitle_name="Complaint Process for Coverage Decisions"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1102" title_number="15" title_name="Health Insurance" subtitle_number="11" subtitle_name="Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans"> <level label="a"> <text>In this section, “employee” includes:</text> <level label="1"> <text>an officer, manager, or retired employee of an employer;</text> </level> <level label="2"> <text>a sole proprietor if the employer is a sole proprietorship; and</text> </level> <level label="3"> <text>a partner if the employer is a partnership.</text> </level> </level> <level label="b"> <text>Health insurance on a franchise plan is the form of health insurance:</text> <level label="1"> <text>that is issued to:</text> <level label="i"> <text>three or more employees of a corporation, partnership, sole proprietorship, or governmental corporation, agency, or department; or</text> </level> <level label="ii"> <text>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;</text> </level> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>under which the premiums on the individual policies may be paid to the insurer periodically by:</text> <level label="i"> <text>the employer, with or without payroll deductions;</text> </level> <level label="ii"> <text>the labor union or association for its members; or</text> </level> <level label="iii"> <text>a designated person acting on behalf of the employer, labor union, or association.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1103" title_number="15" title_name="Health Insurance" subtitle_number="11" subtitle_name="Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans"> <level label="a"> <text>In this section, “transportation ticket policy” means a ticket policy of health insurance that:</text> <level label="1"> <text>has as its dominant feature the protection of the insured from a transportation hazard; and</text> </level> <level label="2"> <text>is sold at transportation stations, ticket offices, or travel bureaus by:</text> <level label="i"> <text>vending machines;</text> </level> <level label="ii"> <text>employees of railroads, steam lines, airlines, or other organizations engaged in transporting individuals on common carriers;</text> </level> <level label="iii"> <text>individuals or employees of persons engaged in selling transportation on common carriers; or</text> </level> <level label="iv"> <text>other qualified agents.</text> </level> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1104" title_number="15" title_name="Health Insurance" subtitle_number="11" subtitle_name="Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Employer sponsored health benefit plan” means any plan, fund, or program that:</text> <level label="i"> <text>is established or maintained by an employer under the Employee Retirement Income Security Act of 1974;</text> </level> <level label="ii"> <text>offers coverage for health benefits; and</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="3"> <text>“Group health insurance” has the meaning stated in § 15–302 of this title.</text> </level> <level label="4"> <text>“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.</text> </level> <level label="5"> <text>“Special eligible employee” means an employee who:</text> <level label="i"> <text>is eligible for health coverage under the terms of an employer sponsored health benefit plan;</text> </level> <level label="ii"> <text>works:</text> <level label="1"> <text>on a temporary or substitute basis; or</text> </level> <level label="2"> <text>less than 30 hours in a normal workweek; and</text> </level> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>special eligible employees; or</text> </level> <level label="2"> <text>special eligible employees and their dependents.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>collect payment for premiums due under the limited benefit group health insurance contract through payroll deduction;</text> </level> <level label="2"> <text>contribute to the premium payments applicable to the coverage of a special eligible employee; and</text> </level> <level label="3"> <text>offer coverage to any dependent of a special eligible employee.</text> </level> </level> <level label="d"> <text>A limited benefit group health insurance contract shall comply with:</text> <level label="1"> <text>this title, except Subtitles 7 and 8 of this title; and</text> </level> <level label="2"> <text>notwithstanding item (1) of this subsection, §§ 15–802, 15–812, 15–815, 15–830, 15–831, 15–832, and 15–833 of this title.</text> </level> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1106" title_number="15" title_name="Health Insurance" subtitle_number="11" subtitle_name="Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Carrier” means:</text> <level label="i"> <text>an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan; or</text> </level> <level label="iii"> <text>a health maintenance organization.</text> </level> </level> <level label="3"> <text>“Evidence of individual insurability” has the meaning stated in § 15–1105 of this subtitle.</text> </level> <level label="4"> <text>“Health benefit plan” has the meaning stated in § 15–1301 of this title.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>The carrier shall have the burden of persuasion that its rescission of a health benefit plan complies with subsection (b) of this section.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1201" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“Board” means the Board of Directors of the Pool established under § 15–1216 of this subtitle.</text> </level> <level label="c"> <text>“Carrier” means a person that:</text> <level label="1"> <text>offers health benefit plans in the State covering eligible employees of small employers; and</text> </level> <level label="2"> <text>is:</text> <level label="i"> <text>an authorized insurer that provides health insurance in the State;</text> </level> <level label="ii"> <text>a nonprofit health service plan that is licensed to operate in the State;</text> </level> <level label="iii"> <text>a health maintenance organization that is licensed to operate in the State; or</text> </level> <level label="iv"> <text>any other person or organization that provides health benefit plans subject to State insurance regulation.</text> </level> </level> </level> <level label="d"> <text>“Commission” means the Maryland Health Care Commission established under Title 19, Subtitle 1 of the Health – General Article.</text> </level> <level label="e"> <text>“Coverage level” has the meaning stated in § 31–101 of this article.</text> </level> <level label="f"> <level label="1"> <text>“Eligible employee” means an employee who is offered coverage under a health benefit plan by a small employer.</text> </level> <level label="2"> <text>“Eligible employee”, at the option of the small employer, may include:</text> <level label="i"> <text>only full–time employees; or</text> </level> <level label="ii"> <text>full–time employees and part–time employees.</text> </level> </level> </level> <level label="g"> <text>“Employee” means an individual who is employed by a small employer.</text> </level> <level label="h"> <level label="1"> <text>“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.</text> </level> <level label="2"> <text>“Full–time employee” does not include a seasonal employee as defined in federal law.</text> </level> </level> <level label="i"> <level label="1"> <text>“Health benefit plan” means:</text> <level label="i"> <text>a policy or certificate for hospital or medical benefits issued by an insurer;</text> </level> <level label="ii"> <text>a nonprofit health service plan contract; or</text> </level> <level label="iii"> <text>a health maintenance organization subscriber or group master contract.</text> </level> </level> <level label="2"> <text>“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:</text> <level label="i"> <text>a multiple employer trust or association located in this State or another state; or</text> </level> <level label="ii"> <text>a professional employer organization, coemployer, or other organization located in this State or another state that engages in employee leasing.</text> </level> </level> <level label="3"> <text>“Health benefit plan” does not include:</text> <level label="i"> <text>accident–only insurance;</text> </level> <level label="ii"> <text>credit health insurance;</text> </level> <level label="iii"> <text>disability income insurance;</text> </level> <level label="iv"> <text>coverage issued as a supplement to liability insurance;</text> </level> <level label="v"> <text>workers’ compensation or similar insurance;</text> </level> <level label="vi"> <text>automobile medical payment insurance;</text> </level> <level label="vii"> <text>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:</text> <level label="1"> <text>dental benefits;</text> </level> <level label="2"> <text>vision benefits; or</text> </level> <level label="3"> <text>long–term care insurance as defined in § 18–101 of this article;</text> </level> </level> <level label="viii"> <text>disease–specific insurance if:</text> <level label="1"> <text>the benefits are provided under a separate policy, certificate, or contract;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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;</text> </level> </level> <level label="ix"> <text>hospital indemnity or other fixed indemnity insurance if:</text> <level label="1"> <text>the benefits are provided under a separate policy, certificate, or contract;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>the benefits are payable in a fixed dollar amount per period of time, regardless of the amount of expenses incurred; or</text> </level> </level> <level label="x"> <text>the following supplemental benefits, if the benefits are provided under a separate policy, certificate, or contract:</text> <level label="1"> <text>a Medicare supplement policy as defined in § 15–901 of this title;</text> </level> <level label="2"> <text>coverage supplemental to the coverage provided under Chapter 55, Title 10 of the United States Code; and</text> </level> <level label="3"> <text>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).</text> </level> </level> </level> </level> <level label="j"> <text>“Health care practitioner” has the meaning stated in § 1–301 of the Health Occupations Article.</text> </level> <level label="k"> <text>“Health status–related factor” means a factor related to:</text> <level label="1"> <text>health status;</text> </level> <level label="2"> <text>medical condition;</text> </level> <level label="3"> <text>claims experience;</text> </level> <level label="4"> <text>receipt of health care;</text> </level> <level label="5"> <text>medical history;</text> </level> <level label="6"> <text>genetic information;</text> </level> <level label="7"> <text>evidence of insurability including conditions arising out of acts of domestic violence; or</text> </level> <level label="8"> <text>disability.</text> </level> </level> <level label="l"> <text>“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.</text> </level> <level label="m"> <text>“Minimum essential coverage” has the meaning stated in 45 C.F.R. § 155.20.</text> </level> <level label="n"> <text>“Part–time employee” means an employee of a small employer who:</text> <level label="1"> <text>has a normal workweek of at least 17.5 hours; and</text> </level> <level label="2"> <text>is not a full–time employee.</text> </level> </level> <level label="o"> <text>“Plan year” means a calendar year or other consecutive 12–month period during which a health benefit plan provides coverage for health care services.</text> </level> <level label="p"> <text>“Pool” means the Maryland Small Employer Health Reinsurance Pool established under this subtitle.</text> </level> <level label="q"> <text>“Preexisting condition” means:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="r"> <text>“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.</text> </level> <level label="s"> <text>“Qualified employer” has the meaning stated in § 31–101 of this article.</text> </level> <level label="t"> <text>“Qualified health plan” has the meaning stated in § 31–101 of this article.</text> </level> <level label="u"> <text>“Reinsuring carrier” means a carrier that participates in the Pool.</text> </level> <level label="v"> <text>“Risk–assuming carrier” means a carrier that does not participate in the Pool.</text> </level> <level label="w"> <text>“SHOP Exchange” has the meaning stated in § 31–101 of this article.</text> </level> <level label="x"> <text>“Small employer” has the meaning stated in § 31–101 of this article.</text> </level> <level label="y"> <text>“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.</text> </level> <level label="z"> <text>“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.</text> </level> <level label="aa"> <text>“Wellness benefit” means a benefit that:</text> <level label="1"> <text>includes a bona fide wellness program as defined in § 15–509 of this title; and</text> </level> <level label="2"> <text>complies with regulations adopted by the Commission.</text> </level> </level> <level label="bb"> <level label="1"> <text>“Wellness program” means a program or activity that:</text> <level label="i"> <text>is designed to improve health status and reduce health care costs; and</text> </level> <level label="ii"> <text>complies with guidelines developed by the Commission.</text> </level> </level> <level label="2"> <text>“Wellness program” includes programs and activities for:</text> <level label="i"> <text>smoking cessation;</text> </level> <level label="ii"> <text>reduction of alcohol misuse;</text> </level> <level label="iii"> <text>weight reduction;</text> </level> <level label="iv"> <text>nutrition education; and</text> </level> <level label="v"> <text>automobile and motorcycle safety.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1202" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>This subtitle applies only to a health benefit plan that:</text> <level label="1"> <text>covers eligible employees of small employers in the State; and</text> </level> <level label="2"> <text>is issued or renewed on or after July 1, 1994, if:</text> <level label="i"> <text>any part of the premium or benefits is paid by or on behalf of the small employer;</text> </level> <level label="ii"> <text>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;</text> </level> <level label="iii"> <text>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</text> </level> <level label="iv"> <text>the small employer allows eligible employees to pay for the health benefit plan through payroll deductions.</text> </level> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1204" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>In addition to any other requirement under this article, a carrier shall:</text> <level label="1"> <text>have demonstrated the capacity to administer the health benefit plan, including adequate numbers and types of administrative personnel;</text> </level> <level label="2"> <text>have a satisfactory grievance procedure and ability to respond to enrollees’ calls, questions, and complaints;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>design policies to help ensure adequate access to providers of health care.</text> </level> </level> <level label="c"> <text>A person may not offer a health benefit plan in the State unless the person offers at least the Standard Plan.</text> </level> <level label="d"> <text>A carrier may not offer a health benefit plan that has fewer benefits than those in the Standard Plan.</text> </level> <level label="e"> <text>A carrier may offer benefits in addition to those in the Standard Plan if:</text> <level label="1"> <text>the additional benefits:</text> <level label="i"> <text>are offered and priced separately from benefits specified in accordance with § 15–1207 of this subtitle; and</text> </level> <level label="ii"> <text>do not have the effect of duplicating any of those benefits; and</text> </level> </level> <level label="2"> <text>the carrier:</text> <level label="i"> <text>clearly distinguishes the Standard Plan from other offerings of the carrier;</text> </level> <level label="ii"> <text>indicates the Standard Plan is the only plan required by State law; and</text> </level> <level label="iii"> <text>specifies that all enhancements to the Standard Plan are not required by State law.</text> </level> </level> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <text>A carrier may offer coverage for dental care and services as an additional benefit.</text> </level> <level label="h"> <level label="1"> <text>In this subsection, “prominent carrier” means a carrier that insures at least 10% of the total lives insured in the small group market.</text> </level> <level label="2"> <level label="i"> <text>A prominent carrier shall offer a wellness benefit for a health benefit plan offered under this subtitle.</text> </level> <level label="ii"> <text>A carrier that is not a prominent carrier may offer a wellness benefit for a health benefit plan offered under this subtitle.</text> </level> </level> <level label="3"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1204.1" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>This section applies to a carrier with respect to any health benefit plan that:</text> <level label="1"> <text>is not a grandfathered health plan, as defined in § 1251 of the Affordable Care Act; and</text> </level> <level label="2"> <text>is issued, delivered, or renewed in the State on or after January 1, 2014.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>A carrier is exempt from the requirement in paragraph (1) of this subsection if:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>the Commissioner determines that the carrier complies with the procedures established under paragraph (3) of this subsection; and</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>Notwithstanding the exemption provided in paragraph (2) of this subsection, the Commissioner, in consultation with the Maryland Health Benefit Exchange:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>shall make any change in the exemption requirement by regulation.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1205" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>A carrier may adjust the community rate only for:</text> <level label="i"> <text>age;</text> </level> <level label="ii"> <text>geography based on the following contiguous areas of the State:</text> <level label="1"> <text>the Baltimore metropolitan area;</text> </level> <level label="2"> <text>the District of Columbia metropolitan area;</text> </level> <level label="3"> <text>Western Maryland; and</text> </level> <level label="4"> <text>Eastern and Southern Maryland; and</text> </level> </level> <level label="iii"> <text>health status, as provided in subsection (g) of this section.</text> </level> </level> <level label="4"> <text>Rates for a health benefit plan may vary based on family composition as approved by the Commissioner.</text> </level> <level label="5"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>A discount offered under subparagraph (i) of this paragraph shall be:</text> <level label="1"> <text>applied to reduce the rate otherwise payable by the small employer;</text> </level> <level label="2"> <text>actuarially justified;</text> </level> <level label="3"> <text>offered uniformly to all small employers; and</text> </level> <level label="4"> <text>approved by the Commissioner.</text> </level> </level> </level> </level> <level label="b"> <level label="1"> <text>This subsection applies to a carrier with respect to any health benefit plan that:</text> <level label="i"> <text>is not a grandfathered health plan, as defined in § 1251 of the Affordable Care Act; and</text> </level> <level label="ii"> <text>is issued, delivered, or renewed in the State on or after January 1, 2014.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>In accordance with § 2701(a) of the Affordable Care Act, a premium rate may vary only by:</text> <level label="i"> <text>whether the health benefit plan covers an individual or a family;</text> </level> <level label="ii"> <text>rating area;</text> </level> <level label="iii"> <text>age, except that a rate may not vary by more than 3 to 1 for adults; and</text> </level> <level label="iv"> <text>tobacco use, except that a rate may not vary by more than 1.5 to 1.</text> </level> </level> <level label="4"> <text>A rate may not vary by any factor that is not specified in paragraph (3) of this subsection.</text> </level> </level> <level label="c"> <level label="1"> <text>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:</text> <level label="i"> <text>issued, delivered, or renewed in the State; and</text> </level> <level label="ii"> <text>grandfathered health plans, as defined in § 1251 of the Affordable Care Act.</text> </level> </level> <level label="2"> <text>A carrier shall apply all risk adjustment factors under subsection (b) of this section consistently with respect to all health benefit plans that are:</text> <level label="i"> <text>issued, delivered, or renewed in the State; and</text> </level> <level label="ii"> <text>not grandfathered health plans, as defined in § 1251 of the Affordable Care Act.</text> </level> </level> </level> <level label="d"> <level label="1"> <text>This subsection applies to a carrier with respect to any health benefit plan that is a grandfathered health plan.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="e"> <level label="1"> <text>A carrier shall base its rating methods and practices on commonly accepted actuarial assumptions and sound actuarial principles.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>use in its rating methodology an adjustment that reflects the subrogation; and</text> </level> <level label="ii"> <text>identify in its rate filing with the Administration, and annually in a form approved by the Commissioner, all amounts recovered through subrogation.</text> </level> </level> </level> <level label="f"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>The administrative discount shall be offered under the same terms and conditions for all qualifying small employers.</text> </level> </level> <level label="g"> <level label="1"> <text>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.</text> </level> <level label="2"> <level label="i"> <text>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:</text> <level label="1"> <text>in the first year of enrollment, a rate that is 10% above or below the community rate;</text> </level> <level label="2"> <text>in the second year of enrollment, a rate that is 5% above or below the community rate; and</text> </level> <level label="3"> <text>in the third year of enrollment, a rate that is 2% above or below the community rate.</text> </level> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="h"> <text>A carrier shall set premium rates for the entire plan year for each small employer.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1206" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <level label="1"> <text>A carrier may not arbitrarily transfer a small employer involuntarily into or out of a health benefit plan.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <text>A carrier shall make a reasonable disclosure in its solicitation and sales materials of:</text> <level label="1"> <text>the provisions that relate to the carrier’s right to change premium rates, including any factors that may affect the changes in premium rates;</text> </level> <level label="2"> <text>the provisions that relate to renewability of policies and contracts;</text> </level> <level label="3"> <text>the provisions that relate to preexisting conditions; and</text> </level> <level label="4"> <text>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.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>A carrier may not impose a requirement for minimum participation by the eligible employees of a small employer that is greater than 75%.</text> </level> <level label="3"> <text>In applying a minimum participation requirement to determine whether the applicable percentage of participation is met, a carrier may not consider as eligible employees:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>employees who are under the age of 26 years who are covered under their parent’s health benefit plan.</text> </level> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>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.</text> </level> <level label="6"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>On or before March 15 of each year, each carrier shall file an actuarial certification with the Commissioner.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>A carrier shall:</text> <level label="i"> <text>retain all information and documentation required under this subtitle at its principal place of business for a period of 5 years; and</text> </level> <level label="ii"> <text>make the information and documentation available to the Commissioner on request.</text> </level> </level> </level> <level label="f"> <text>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:</text> <level label="1"> <text>is inversely related to the size of the small employer group;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>is established by a contract between the carrier and each outside producer, and the carrier:</text> <level label="i"> <text>specifies in the contract the group size to which the variation applies;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>pays a commission to the employee producer described in item (ii) of this item.</text> </level> </level> </level> <level label="g"> <level label="1"> <text>A licensed insurance producer, in connection with the sale, solicitation, or negotiation of a health benefit plan to a small employer, shall:</text> <level label="i"> <text>provide information to the small employer about wellness benefits; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>The information shall be provided:</text> <level label="i"> <text>whenever the employer purchases or renews a health benefit plan; and</text> </level> <level label="ii"> <text>on request.</text> </level> </level> </level> <level label="h"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>income eligibility thresholds; and</text> </level> <level label="ii"> <text>application instructions.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1207" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>In accordance with Title 19, Subtitle 1 of the Health – General Article, the Commission shall adopt regulations that specify:</text> <level label="1"> <text>the Comprehensive Standard Health Benefit Plan to apply under this subtitle; and</text> </level> <level label="2"> <text>the requirements for a wellness benefit offered by a carrier to apply under this subtitle.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>In establishing benefits, the Commission shall judge preventive services, medical treatments, procedures, and related health services based on:</text> <level label="1"> <text>their effectiveness in improving the health status of individuals;</text> </level> <level label="2"> <text>their impact on maintaining and improving health and on reducing the unnecessary consumption of health care services; and</text> </level> <level label="3"> <text>their impact on the affordability of health care coverage.</text> </level> </level> <level label="d"> <text>The Commission may exclude:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>The Commission shall specify the deductibles and cost–sharing associated with the benefits in the Standard Plan.</text> </level> <level label="g"> <text>In establishing cost–sharing as part of the Standard Plan, the Commission shall:</text> <level label="1"> <text>include cost–sharing and other incentives to help prevent consumers from seeking unnecessary services;</text> </level> <level label="2"> <text>balance the effect of cost–sharing in reducing premiums and in affecting utilization of appropriate services; and</text> </level> <level label="3"> <text>limit the total cost–sharing that may be incurred by an individual in a year.</text> </level> </level> <level label="h"> <text>Beginning January 1, 2014, this section applies only to grandfathered health plans as defined in § 1251 of the Affordable Care Act.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1208" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <text>The provisions of § 15–508 of this title apply to a policy or certificate issued to a small employer.</text> </section> <section article="gin" article_name="Insurance" number="15-1208.1" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>A carrier shall provide the special enrollment periods described in this section in each small employer health benefit plan.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>the eligible employee’s or dependent’s coverage described in item (1) of this subsection:</text> <level label="i"> <text>was under a COBRA continuation provision, and the coverage under that provision was exhausted; or</text> </level> <level label="ii"> <text>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</text> </level> </level> <level label="4"> <text>under the terms of the plan, the eligible employee requests enrollment not later than 30 days after:</text> <level label="i"> <text>the date of exhaustion of coverage described in item (3)(i) of this subsection; or</text> </level> <level label="ii"> <text>termination of coverage or termination of employer contributions described in item (3)(ii) of this subsection.</text> </level> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>an individual who becomes a dependent of the eligible employee through marriage, birth, adoption, placement for adoption, or placement for foster care;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>at the option of the SHOP Exchange, an enrollee who is the eligible employee or the spouse of the eligible employee, if:</text> <level label="i"> <text>the enrollee loses a dependent or is no longer considered to be a dependent due to divorce or legal separation; or</text> </level> <level label="ii"> <text>the employee or the employee’s dependent dies; and</text> </level> </level> <level label="5"> <level label="i"> <text>an eligible employee who becomes pregnant, as confirmed by a health care practitioner; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="d"> <text>An eligible employee may not enroll a dependent during a special enrollment period unless the eligible employee:</text> <level label="1"> <text>is enrolled under the health benefit plan; or</text> </level> <level label="2"> <text>applies for coverage for the eligible employee during the same special enrollment period.</text> </level> </level> <level label="e"> <level label="1"> <text>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:</text> <level label="i"> <text>the date dependent coverage is made available; or</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>The special enrollment period under subsection (c)(5) of this section shall:</text> <level label="i"> <text>be open for a period of 90 days; and</text> </level> <level label="ii"> <text>begin on the date a health care practitioner confirms the pregnancy.</text> </level> </level> </level> <level label="f"> <level label="1"> <text>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:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>in the case of a dependent’s birth, as of the date of the dependent’s birth;</text> </level> <level label="iii"> <text>in the case of a dependent’s adoption or placement for adoption, the date of adoption or placement for adoption, whichever occurs first;</text> </level> <level label="iv"> <text>in the case of a dependent’s placement for foster care, the date of placement; and</text> </level> <level label="v"> <text>in the case of a dependent added due to a child support order or any other court order:</text> <level label="1"> <text>the date the child support order or other court order is effective; or</text> </level> <level label="2"> <text>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.</text> </level> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="g"> <text>If the SHOP Exchange allows the special enrollment periods described in subsection (c)(4) of this section, the coverage shall become effective as follows:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1208.2" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Qualifying coverage in an eligible employer–sponsored plan” has the meaning stated in 45 C.F.R. § 155.300.</text> </level> </level> <level label="b"> <level label="1"> <text>A carrier shall establish a standardized annual open enrollment period of at least 30 days for each small employer.</text> </level> <level label="2"> <text>The annual open enrollment period shall occur before the end of the small employer’s plan year.</text> </level> <level label="3"> <text>During the annual open enrollment period, each eligible employee of the small employer shall be permitted to:</text> <level label="i"> <text>enroll in a health benefit plan offered by the small employer;</text> </level> <level label="ii"> <text>discontinue enrollment in a health benefit plan offered by the small employer; or</text> </level> <level label="iii"> <text>change enrollment from one health benefit plan offered by the small employer to a different health benefit plan offered by the small employer.</text> </level> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>A carrier shall provide an open enrollment period for each individual who experiences a triggering event described in paragraph (4) of this subsection.</text> </level> <level label="2"> <text>The open enrollment period shall be for at least 30 days, beginning on the date of the triggering event.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>A triggering event occurs when:</text> <level label="i"> <text>subject to paragraph (5) of this subsection, an eligible employee or dependent loses minimum essential coverage;</text> </level> <level label="ii"> <text>an eligible employee or a dependent loses:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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;</text> </level> </level> <level label="iii"> <text>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;</text> </level> <level label="iv"> <text>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;</text> </level> <level label="v"> <text>an eligible employee or a dependent:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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;</text> </level> </level> <level label="vi"> <text>for SHOP Exchange health benefit plans:</text> <level label="1"> <text>an eligible employee’s or a dependent’s enrollment or nonenrollment in a qualified health plan is, as evaluated and determined by the Exchange:</text> </level> <level label="A"> <text>unintentional, inadvertent, or erroneous; and</text> </level> <level label="B"> <text>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;</text> </level> <level label="2"> <text>an eligible employee is an Indian as defined in § 4 of the federal Indian Health Care Improvement Act;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>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;</text> </level> </level> <level label="vii"> <text>an eligible employee or dependent:</text> <level label="1"> <text>is a victim of domestic abuse or spousal abandonment, as defined by 26 C.F.R. § 1.36B–2T;</text> </level> <level label="2"> <text>is enrolled in minimum essential coverage; and</text> </level> <level label="3"> <text>seeks to enroll in coverage separate from the perpetrator of the abuse or abandonment;</text> </level> </level> <level label="viii"> <text>an eligible employee or dependent:</text> <level label="1"> <text>applies for coverage through the Individual Exchange during the annual open enrollment period or a special enrollment period;</text> </level> <level label="2"> <text>is assessed by the Individual Exchange as potentially eligible for the Maryland Medical Assistance Program or the Maryland Children’s Health Program; and</text> </level> <level label="3"> <text>is determined ineligible for the Maryland Medical Assistance Program or the Maryland Children’s Health Program by the Maryland Department of Health either:</text> </level> <level label="A"> <text>after open enrollment has ended; or</text> </level> <level label="B"> <text>more than 60 days after the qualifying event;</text> </level> </level> <level label="ix"> <text>an eligible employee or dependent:</text> <level label="1"> <text>applies for coverage through the Maryland Medical Assistance Program or the Maryland Children’s Health Program during the annual open enrollment period; and</text> </level> <level label="2"> <text>is determined ineligible for the Maryland Medical Assistance Program or the Maryland Children’s Health Program after open enrollment has ended; or</text> </level> </level> <level label="x"> <text>an eligible employee or dependent gains access to new qualified health plans as a result of a permanent move and either:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>lived in a service area where no qualified health plan was available through the Exchange:</text> </level> <level label="A"> <text>for 1 or more days during the 60 days before the date of the permanent move; or</text> </level> <level label="B"> <text>during the eligible employee’s or dependent’s most recent preceding open enrollment period or special enrollment period;</text> </level> <level label="4"> <text>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</text> </level> <level label="5"> <text>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.</text> </level> </level> </level> <level label="5"> <text>Loss of minimum essential coverage under paragraph (4)(i) of this subsection does not include loss of coverage due to:</text> <level label="i"> <text>voluntary termination of coverage;</text> </level> <level label="ii"> <text>failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; or</text> </level> <level label="iii"> <text>a rescission authorized under 45 C.F.R. § 147.128.</text> </level> </level> <level label="6"> <text>The triggering event described in paragraph (4)(iii) of this subsection is permitted only once per year per individual.</text> </level> <level label="7"> <text>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.</text> </level> <level label="8"> <text>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.</text> </level> <level label="9"> <text>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.</text> </level> <level label="10"> <text>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.</text> </level> <level label="11"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1209" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>This section does not apply to any insurance enumerated in § 15–1201(i)(3)(i) through (xiii) of this subtitle.</text> </level> <level label="b"> <text>A carrier shall issue its health benefit plans to each small employer that meets the requirements of this section.</text> </level> <level label="c"> <level label="1"> <text>Nothing in this subsection requires a small employer to contribute to the premium payments for coverage of a dependent of an eligible employee.</text> </level> <level label="2"> <text>To be covered under a health benefit plan offered by a carrier, a small employer shall:</text> <level label="i"> <text>elect to be covered;</text> </level> <level label="ii"> <text>agree to pay the premiums;</text> </level> <level label="iii"> <text>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;</text> </level> <level label="iv"> <text>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</text> </level> <level label="v"> <text>satisfy other reasonable provisions of the health benefit plan as approved by the Commissioner.</text> </level> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>A carrier may vary application of minimum participation of eligible employees only by the size of the group of the small employer.</text> </level> </level> <level label="e"> <text>A carrier may not require a small employer to contribute to payment of premiums for a health benefit plan.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1210" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>A carrier that offers coverage to a small employer shall:</text> <level label="1"> <text>offer coverage to all of its eligible employees and all of their eligible dependents; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <level label="1"> <text>A health maintenance organization need not offer coverage:</text> <level label="i"> <text>to a small employer that is outside of the health maintenance organization’s approved service areas;</text> </level> <level label="ii"> <text>to an eligible employee who resides outside of the health maintenance organization’s approved service areas; or</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>180 days after a refusal to do so; or</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1211" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>Unless the Commissioner previously has disapproved a health benefit plan, it is deemed approved 60 days after filing with the Commissioner.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1212" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <level label="i"> <text>“Product” means a discrete package of health benefits that are offered using a particular product network type within a geographic service area.</text> </level> <level label="ii"> <text>“Product” comprises all plans offered within the product.</text> </level> </level> <level label="4"> <text>“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).</text> </level> </level> <level label="b"> <text>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).</text> </level> <level label="c"> <text>The combination of all plans offered with a product constitutes the total service area of the product.</text> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <level label="1"> <text>the plan has the same cost–sharing structure as before the modification; or</text> </level> <level label="2"> <text>any variation in cost sharing:</text> </level> <level label="A"> <text>is solely related to changes in cost or utilization of medical care; or</text> </level> <level label="B"> <text>is to maintain the same metal level described in § 1302(d) and (e) of the Affordable Care Act;</text> </level> </level> <level label="ii"> <text>the plan continues to cover a majority of the same service area; and</text> </level> <level label="iii"> <text>the plan continues to cover a majority of the same provider network.</text> </level> </level> <level label="2"> <text>Notwithstanding paragraph (1) of this subsection, the plan shall be considered to be the same plan to the extent that the modifications are:</text> <level label="i"> <text>made uniformly and solely as a result of a federal or State requirement;</text> </level> <level label="ii"> <text>made within a reasonable time period after the imposition or modification of the federal or State requirement; and</text> </level> <level label="iii"> <text>directly related to the imposition or modification of the federal or State requirement.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>On renewal, a carrier may not exclude eligible employees or dependents from a health benefit plan.</text> </level> <level label="3"> <level label="i"> <text>A carrier shall mail a notice of renewal to the small employer at least 60 days before the expiration of a health benefit plan.</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="4"> <text>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.</text> </level> </level> <level label="f"> <text>A carrier may cancel or refuse to renew a health benefit plan only:</text> <level label="1"> <text>for nonpayment of premiums;</text> </level> <level label="2"> <text>for fraud or intentional misrepresentation of material fact by the small employer;</text> </level> <level label="3"> <text>for noncompliance with a material plan provision relating to employer contributions or group participation rules;</text> </level> <level label="4"> <text>when the carrier elects not to renew:</text> <level label="i"> <text>all of its health benefit plans that are issued to small employers in the State; or</text> </level> <level label="ii"> <text>the particular product for all small employers in the State; or</text> </level> </level> <level label="5"> <text>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.</text> </level> </level> <level label="g"> <text>When a carrier elects not to renew all health benefit plans in the State, the carrier:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>shall give notice to the Commissioner at least 30 working days before giving the notice specified in item (1) of this subsection; and</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="h"> <text>When a carrier elects not to renew a particular product for all small employers in the State, the carrier shall:</text> <level label="1"> <text>provide notice of the nonrenewal at least 90 days before the date of the nonrenewal to:</text> <level label="i"> <text>each affected:</text> <level label="1"> <text>small employer; and</text> </level> <level label="2"> <text>enrolled employee; and</text> </level> </level> <level label="ii"> <text>the Commissioner;</text> </level> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>act uniformly without regard to the claims experience of any affected small employer, or any health status–related factor of any affected individual.</text> </level> </level> <level label="i"> <level label="1"> <text>Within 7 days after cancellation or nonrenewal of a health benefit plan, the carrier shall send to each enrolled employee:</text> <level label="i"> <text>written notice of its action; and</text> </level> <level label="ii"> <text>notice delivered by electronic means that complies with § 27–601.2 of this article.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="j"> <text>A carrier may make a uniform modification of coverage for a product only at the time of renewal of the health benefit plan.</text> </level> <level label="k"> <text>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).</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1213" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>This section does not apply to any insurance enumerated in § 15–1201(i)(3)(i) through (xiii) of this subtitle.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>guaranteed issuance;</text> </level> <level label="2"> <text>guaranteed renewal; and</text> </level> <level label="3"> <text>adjusted community rating.</text> </level> </level> <level label="c"> <level label="1"> <text>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:</text> <level label="i"> <text>guaranteed renewal; and</text> </level> <level label="ii"> <text>adjusted community rating.</text> </level> </level> <level label="2"> <text>For each additional benefit offered under this subsection, a carrier shall accept or reject the application of the entire group.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="d"> <text>Beginning January 1, 2014, this section applies only to grandfathered health plans as defined in § 1251 of the Affordable Care Act.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1214" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1215" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <level label="1"> <text>Each carrier shall elect to become either a risk-assuming carrier or reinsuring carrier.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="b"> <level label="1"> <text>The initial election under this section is binding for 3 years.</text> </level> <level label="2"> <text>After the initial 3 years, and every 5 years thereafter, each carrier shall again elect to be either a risk-assuming or reinsuring carrier.</text> </level> <level label="3"> <text>Each subsequent election is binding for 5 years.</text> </level> <level label="4"> <text>The Commissioner may allow a new carrier to make an election under conditions established by the Commissioner.</text> </level> </level> <level label="c"> <level label="1"> <text>The Commissioner may allow a carrier to change its election at any time for good cause shown.</text> </level> <level label="2"> <text>In determining whether to approve an application by a carrier to change its election, the Commissioner shall consider:</text> <level label="i"> <text>the applicant’s financial condition and the financial condition of any parent or guaranteeing corporation;</text> </level> <level label="ii"> <text>the applicant’s history of assuming and managing risk;</text> </level> <level label="iii"> <text>the applicant’s commitment to market fairly to all small employers in the State or in the applicant’s service area;</text> </level> <level label="iv"> <text>the applicant’s ability to assume and manage the risk of enrolling groups under this subtitle without the protection of the Pool; and</text> </level> <level label="v"> <text>the effect of approval of the application on the financial viability of the Pool.</text> </level> </level> <level label="3"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1216" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>The Commissioner shall establish the Maryland Small Employer Health Reinsurance Pool.</text> </level> <level label="b"> <text>The Pool shall be operational and may reinsure claims in accordance with this subtitle on or after July 1, 1994.</text> </level> <level label="c"> <level label="1"> <text>The reinsuring carriers shall elect a Board of Directors to be composed of seven members.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>A carrier, including its affiliates, may not be represented by more than one member on the Board.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>At the end of a term, a member continues to serve until a successor is elected.</text> </level> <level label="6"> <text>Vacancies shall be filled by an election of the remaining Board members.</text> </level> <level label="7"> <text>A member who is elected after a term has begun serves only for the rest of the term and until a successor is elected.</text> </level> <level label="8"> <text>A member who serves two consecutive full 3–year terms may not be reelected for 3 years after the completion of those terms.</text> </level> </level> <level label="d"> <text>The Board shall choose a Chairman.</text> </level> <level label="e"> <level label="1"> <text>The Board shall appoint an Executive Director, who shall be the chief administrative officer of the Pool.</text> </level> <level label="2"> <text>The Executive Director serves at the pleasure of the Board.</text> </level> <level label="3"> <text>Under the direction of the Board, the Executive Director shall perform any duty or function that the Board requires.</text> </level> </level> <level label="f"> <text>The Pool may employ a staff in accordance with the budget of the Pool.</text> </level> <level label="g"> <level label="1"> <text>The Board shall submit to the Commissioner a plan of operation to ensure the fair, reasonable, and financially sound administration of the Pool.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1217" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>At a minimum, the plan of operation shall:</text> <level label="1"> <text>establish procedures for the handling and accounting of Pool assets and money and for an annual fiscal report to the Commissioner;</text> </level> <level label="2"> <text>establish procedures for reinsuring claims submitted to the Pool in accordance with this subtitle;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>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</text> </level> <level label="5"> <text>provide for any additional matters at the discretion of the Board.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>The Board may:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>sue or be sued;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>define the health benefit plans and medical conditions for which claims may be reinsured with the Pool in accordance with this subtitle;</text> </level> <level label="5"> <text>establish rules, conditions, and procedures that relate to reinsurance of claims by the Pool;</text> </level> <level label="6"> <text>establish actuarial functions as appropriate for the operation of the Pool;</text> </level> <level label="7"> <text>assess reinsuring carriers in accordance with the provisions of § 15–1221 of this subtitle;</text> </level> <level label="8"> <text>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;</text> </level> <level label="9"> <text>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</text> </level> <level label="10"> <text>borrow money to carry out the purposes of the Pool.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1218" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>A reinsuring carrier may reinsure with the Pool as provided in this section.</text> </level> <level label="b"> <text>At a minimum, the Pool shall reinsure up to the level of coverage specified under the Standard Plan.</text> </level> <level label="c"> <text>A reinsuring carrier may reinsure an entire employer group within 60 days after commencement of the group’s coverage under a health benefit plan.</text> </level> <level label="d"> <level label="1"> <text>A reinsuring carrier may reinsure an eligible employee or dependent within 60 days after commencement of coverage with the small employer.</text> </level> <level label="2"> <text>A reinsuring carrier may reinsure a newly eligible employee or dependent within 60 days after commencement of coverage of the eligible employee or dependent.</text> </level> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>The liability of a reinsuring carrier under this subsection may not exceed $10,000 in any 1 calendar year with respect to any individual.</text> </level> </level> <level label="f"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="g"> <text>A reinsuring carrier may terminate reinsurance on a plan anniversary for one or more of the individuals in a small employer group.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1219" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <level label="1"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="2"> <text>Premiums for the Pool shall be as follows:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>an individual may be reinsured for a rate that is 5 times the base reinsurance premium rate for the individual established under this subsection.</text> </level> </level> <level label="3"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>The Board may propose changes to the methodology, subject to the approval of the Commissioner.</text> </level> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1220" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>All operating expenses of the Pool shall be paid from funds collected by or on behalf of the Pool.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>The Pool is exempt from:</text> <level label="1"> <text>taxation by the State and local government;</text> </level> <level label="2"> <text>the general procurement law provisions of Division II of the State Finance and Procurement Article; and</text> </level> <level label="3"> <text>Division I of the State Personnel and Pensions Article.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1221" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>Any net loss for the year shall be recouped by assessments imposed on reinsuring carriers.</text> </level> <level label="c"> <level label="1"> <text>As part of the plan of operation, the Board shall establish a formula to make assessments against reinsuring carriers.</text> </level> <level label="2"> <text>The assessment formula shall be based on:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>As appropriate and with the approval of the Commissioner, the Board may change the assessment formula established in accordance with this subsection.</text> </level> <level label="5"> <text>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.</text> </level> <level label="6"> <text>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.</text> </level> <level label="7"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>The evaluation required under paragraph (2) of this subsection shall include:</text> <level label="i"> <text>any recommendations for changes to the plan of operation;</text> </level> <level label="ii"> <text>an estimate of future assessments;</text> </level> <level label="iii"> <text>the administrative costs of the Pool;</text> </level> <level label="iv"> <text>the appropriateness of the premiums charged;</text> </level> <level label="v"> <text>the level of insurer retention under the Pool; and</text> </level> <level label="vi"> <text>the costs of coverage for small employers.</text> </level> </level> <level label="4"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> <level label="g"> <text>The plan of operation shall provide for imposition of an interest penalty for late payment of assessments.</text> </level> <level label="h"> <level label="1"> <level label="i"> <text>A reinsuring carrier may seek from the Commissioner a deferment from all or part of an assessment imposed by the Board.</text> </level> <level label="ii"> <text>The request for deferment shall be made in writing to the Commissioner within 15 days after receipt of the assessment notice.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1222" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <level label="a"> <level label="1"> <text>The Board shall report to the Commissioner on or before June 1 of each year.</text> </level> <level label="2"> <text>At a minimum, the report shall include:</text> <level label="i"> <text>a description of the operations of the Pool for the preceding calendar year;</text> </level> <level label="ii"> <text>an audited statement of the financial condition of the Pool as of the preceding December 31; and</text> </level> <level label="iii"> <text>an audited detailed statement of the revenues received and expenditures of the Pool made during the preceding calendar year.</text> </level> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1223" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1224" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1225" title_number="15" title_name="Health Insurance" subtitle_number="12" subtitle_name="Maryland Health Insurance Reform Act"> <text>This subtitle is the Maryland Health Insurance Reform Act.</text> </section> <section article="gin" article_name="Insurance" number="15-1301" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“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.</text> </level> <level label="c"> <text>“Association” or “bona fide association” means an association that:</text> <level label="1"> <text>has been actively in existence for at least 5 years;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>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;</text> </level> <level label="5"> <text>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</text> </level> <level label="6"> <text>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.</text> </level> </level> <level label="d"> <text>“Benefit year” means a calendar year in which a health benefit plan provides coverage for health benefits.</text> </level> <level label="e"> <text>“Carrier” means a person that is:</text> <level label="1"> <text>an insurer that holds a certificate of authority in the State and provides health insurance in the State;</text> </level> <level label="2"> <text>a health maintenance organization that is licensed to operate in the State;</text> </level> <level label="3"> <text>a nonprofit health service plan that is licensed to operate in the State; or</text> </level> <level label="4"> <text>any other person or organization that provides health benefit plans subject to State insurance regulation.</text> </level> </level> <level label="f"> <text>“Church plan” means a plan as defined under § 3(33) of the Employee Retirement Income Security Act of 1974.</text> </level> <level label="g"> <text>“Eligible individual” means an individual who applies for or is covered under an individual health benefit plan.</text> </level> <level label="h"> <text>“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.</text> </level> <level label="i"> <text>“Enrollment date” means the date on which:</text> <level label="1"> <text>an individual enrolls in a health benefit plan; or</text> </level> <level label="2"> <text>the first day of the waiting period before which the individual may enroll.</text> </level> </level> <level label="j"> <text>“Governmental plan” means a plan as defined in § 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan.</text> </level> <level label="k"> <text>“Grandfathered health plan coverage” has the meaning stated in 45 C.F.R. § 147.140.</text> </level> <level label="l"> <level label="1"> <text>“Health benefit plan” means a:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>policy, contract, or certificate issued by a nonprofit health service plan that covers Maryland residents; or</text> </level> <level label="iii"> <text>health maintenance organization subscriber or group master contract.</text> </level> </level> <level label="2"> <text>“Health benefit plan” does not include:</text> <level label="i"> <text>one or more, or any combination of the following:</text> <level label="1"> <text>coverage only for accident or disability income insurance;</text> </level> <level label="2"> <text>coverage issued as a supplement to liability insurance;</text> </level> <level label="3"> <text>liability insurance, including general liability insurance and automobile liability insurance;</text> </level> <level label="4"> <text>workers’ compensation or similar insurance;</text> </level> <level label="5"> <text>automobile medical payment insurance;</text> </level> <level label="6"> <text>credit–only insurance; and</text> </level> <level label="7"> <text>coverage for on–site medical clinics;</text> </level> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>limited scope dental or vision benefits; and</text> </level> <level label="2"> <text>benefits for long–term care, nursing home care, home health care, community–based care, or any combination of these benefits;</text> </level> </level> <level label="iii"> <text>coverage only for a specified disease or illness if offered as independent, noncoordinated benefits;</text> </level> <level label="iv"> <text>hospital indemnity or other fixed indemnity insurance if:</text> <level label="1"> <text>offered as independent, noncoordinated benefits;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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</text> </level> </level> <level label="v"> <text>the following benefits if offered as a separate insurance policy:</text> <level label="1"> <text>Medicare supplemental health insurance (as defined under § 1882(g)(1) of the Social Security Act);</text> </level> <level label="2"> <text>coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and</text> </level> <level label="3"> <text>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).</text> </level> </level> </level> </level> <level label="m"> <text>“Health status–related factor” means a factor related to:</text> <level label="1"> <text>health status;</text> </level> <level label="2"> <text>medical condition;</text> </level> <level label="3"> <text>claims experience;</text> </level> <level label="4"> <text>receipt of health care;</text> </level> <level label="5"> <text>medical history;</text> </level> <level label="6"> <text>genetic information;</text> </level> <level label="7"> <text>evidence of insurability including conditions arising out of acts of domestic violence; or</text> </level> <level label="8"> <text>disability.</text> </level> </level> <level label="n"> <text>“Individual Exchange” has the meaning stated in § 31–101 of this article.</text> </level> <level label="o"> <level label="1"> <text>“Individual health benefit plan” means:</text> <level label="i"> <text>a health benefit plan other than a converted policy or a professional association plan for eligible individuals and their dependents; or</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>“Individual health benefit plan” does not include short–term limited duration insurance.</text> </level> </level> <level label="p"> <text>“Minimum essential coverage” has the meaning stated in 45 C.F.R. § 155.20.</text> </level> <level label="q"> <text>“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.</text> </level> <level label="r"> <text>“Qualified health plan” has the meaning stated in § 31–101 of this article.</text> </level> <level label="s"> <text>“Short–term limited duration insurance” means health insurance coverage provided under a policy or contract with a carrier and that:</text> <level label="1"> <text>has a policy term that is less than 3 months after the original effective date of the policy or contract;</text> </level> <level label="2"> <text>may not be extended or renewed;</text> </level> <level label="3"> <text>applies the same underwriting standards to all applicants regardless of whether they have previously been covered by short–term limited duration insurance; and</text> </level> <level label="4"> <text>contains the notice required by federal law prominently displayed in the contract and in any application materials provided in connection with enrollment.</text> </level> </level> <level label="t"> <text>“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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1302" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <text>This subtitle applies to all carriers that offer health benefit plans to individuals in the State.</text> </level> <level label="b"> <text>This subtitle does not apply to a carrier that offers only conversion policies as required by law.</text> </level> <level label="c"> <text>This subtitle does not apply to a carrier that offers health insurance coverage only in connection with group health plans.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1303" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <text>In addition to any other requirements under this article, a carrier that offers individual health benefit plans in the State shall:</text> <level label="1"> <text>have demonstrated the capacity to administer the individual health benefit plans, including adequate numbers and types of administrative staff;</text> </level> <level label="2"> <text>have a satisfactory grievance procedure and ability to respond to calls, questions, and complaints from enrollees or insureds; and</text> </level> <level label="3"> <text>design policies to help ensure that enrollees or insureds have adequate access to providers of health care.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>A carrier is exempt from the requirement in paragraph (1) of this subsection if:</text> <level label="i"> <level label="1"> <text>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</text> </level> <level label="2"> <text>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;</text> </level> </level> <level label="ii"> <text>the Commissioner determines that the carrier complies with the procedures established under paragraph (3) of this subsection; and</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>Notwithstanding the exemption provided in paragraph (2) of this subsection, the Commissioner, in consultation with the Maryland Health Benefit Exchange:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>shall make any change in the exemption requirement by regulation.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1307" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>A carrier shall submit any information the Commissioner may require to support and justify the carrier’s calculations of actuarial values.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1308" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>A carrier may elect not to renew all individual health benefit plans in the State.</text> </level> <level label="c"> <text>When a carrier elects not to renew all individual health benefit plans in the State, the carrier:</text> <level label="1"> <text>shall give notice of its decision to the affected individuals at least 180 days before the effective date of nonrenewal;</text> </level> <level label="2"> <text>at least 30 working days before that notice, shall give notice to the Commissioner;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>may not write new business for individuals in the State for a 5-year period beginning on the date of notice to the Commissioner.</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <text>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).</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1309" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <level label="i"> <text>“Product” means a discrete package of health benefits that are offered using a particular product network type within a geographic service area.</text> </level> <level label="ii"> <text>“Product” comprises all plans offered within the product.</text> </level> </level> <level label="4"> <text>“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).</text> </level> </level> <level label="b"> <text>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).</text> </level> <level label="c"> <text>The combination of all plans offered with a product constitutes the total service area of the product.</text> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <level label="1"> <text>the plan has the same cost–sharing structure as before the modification; or</text> </level> <level label="2"> <text>any variation in cost sharing:</text> </level> <level label="A"> <text>is solely related to changes in cost or utilization of medical care; or</text> </level> <level label="B"> <text>is to maintain the same metal level described in § 1302(d) and (e) of the Affordable Care Act;</text> </level> </level> <level label="ii"> <text>the plan continues to cover a majority of the same service area; and</text> </level> <level label="iii"> <text>the plan continues to cover a majority of the same provider network.</text> </level> </level> <level label="2"> <text>Notwithstanding paragraph (1) of this subsection, the plan shall be considered to be the same plan to the extent that the modifications are:</text> <level label="i"> <text>made uniformly and solely as a result of a federal or State requirement;</text> </level> <level label="ii"> <text>made within a reasonable time period after the imposition or modification of the federal or State requirement; and</text> </level> <level label="iii"> <text>directly related to the imposition or modification of the federal or State requirement.</text> </level> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>A carrier may not cancel or refuse to renew an individual health benefit plan except:</text> <level label="1"> <text>for nonpayment of the required premiums;</text> </level> <level label="2"> <text>where the individual has performed an act or practice that constitutes fraud;</text> </level> <level label="3"> <text>where the individual has made an intentional misrepresentation of material fact under the terms of the coverage;</text> </level> <level label="4"> <text>where the carrier elects not to renew all of its individual health benefit plans in the State in accordance with this article;</text> </level> <level label="5"> <text>where the individual no longer resides, lives, or works in the service area, provided that:</text> <level label="i"> <text>the coverage is terminated under this provision uniformly without regard to any health status–related factor of covered individuals; and</text> </level> <level label="ii"> <text>notice of the termination is provided to the individual at least 90 calendar days before the date coverage will be terminated; or</text> </level> </level> <level label="6"> <text>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:</text> <level label="i"> <text>at least 90 days before discontinuation of the product, provides notice of the discontinuation to each individual provided coverage under the product;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>acts uniformly without regard to any health status–related factor of enrolled individuals or individuals who may become eligible for the coverage.</text> </level> </level> </level> <level label="g"> <text>A carrier may make a uniform modification of coverage for a product only at the time of renewal of the health benefit plan.</text> </level> <level label="h"> <text>A carrier shall provide notice of renewal or uniform modification of coverage for:</text> <level label="1"> <text>grandfathered health plan coverage, at least 60 days before the date the coverage will be renewed; and</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="i"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1313" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1314" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1315" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Individual Exchange” has the meaning stated in § 31–101 of this article.</text> </level> <level label="3"> <text>“Qualified health plan” has the meaning stated in § 31–101 of this article.</text> </level> <level label="4"> <text>“Qualified individual” has the meaning stated in § 31–101 of this article.</text> </level> </level> <level label="b"> <text>This section applies to a qualified health plan that is issued on or after January 1, 2014, by a carrier through the Individual Exchange.</text> </level> <level label="c"> <text>A qualified health plan subject to this section shall include a grace period provision applicable to a qualified individual who:</text> <level label="1"> <text>is receiving advance payments of federal premium tax credits; and</text> </level> <level label="2"> <text>fails to pay premiums timely.</text> </level> </level> <level label="d"> <text>The grace period provision shall:</text> <level label="1"> <text>provide a grace period of 3 consecutive months after the initial premium payment to begin coverage has been paid;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>be in addition to any other grace period provision required by any other applicable State law.</text> </level> </level> <level label="e"> <text>During the grace period, a carrier that issues a qualified health plan subject to this section:</text> <level label="1"> <text>shall pay all appropriate claims for services rendered to the qualified individual during the first month of the grace period;</text> </level> <level label="2"> <text>may pend claims for services rendered to the qualified individual in the second and third months of the grace period;</text> </level> <level label="3"> <text>shall notify the federal Department of Health and Human Services that the qualified individual is in the grace period; and</text> </level> <level label="4"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1316" future_version_removed="true" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“Health care practitioner” has the meaning stated in § 1–301 of the Health Occupations Article.</text> </level> <level label="4"> <text>“Provider” means a health care practitioner or a health care facility that participates on a health benefit plan’s provider panel.</text> </level> <level label="5"> <text>“Qualifying coverage in an eligible employer–sponsored plan” has the meaning stated in 45 C.F.R. § 155.300.</text> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>The annual open enrollment period for years beginning on and after January 1, 2015, shall be:</text> <level label="i"> <text>the dates adopted by the federal Department of Health and Human Services; or</text> </level> <level label="ii"> <text>if authorized by the federal Department of Health and Human Services, the dates adopted by the Exchange.</text> </level> </level> <level label="4"> <text>During the annual open enrollment period, an individual shall be permitted to:</text> <level label="i"> <text>enroll in a health benefit plan offered by the carrier;</text> </level> <level label="ii"> <text>discontinue enrollment in a health benefit plan offered by the carrier; or</text> </level> <level label="iii"> <text>change enrollment in a health benefit plan offered by the carrier to a different health benefit plan offered by the carrier.</text> </level> </level> <level label="5"> <text>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:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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.</text> </level> </level> <level label="6"> <text>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:</text> <level label="i"> <text>the date adopted by the federal Department of Health and Human Services; or</text> </level> <level label="ii"> <text>if authorized by the federal Department of Health and Human Services, the date adopted by the Exchange.</text> </level> </level> </level> <level label="c"> <text>A carrier participating in the Individual Exchange shall provide:</text> <level label="1"> <text>the special enrollment periods specified in 45 C.F.R. § 155.420 for individuals who purchase coverage through the Individual Exchange;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>a special enrollment period for an individual who purchases coverage through the Individual Exchange if the individual or a dependent of the individual is:</text> <level label="i"> <text>a patient being treated on a regular basis by or at a provider; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="d"> <text>A carrier shall provide:</text> <level label="1"> <text>the special enrollment periods specified in 45 C.F.R. § 147.104(b)(2) for individuals who purchase coverage outside the Individual Exchange;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>a special enrollment period for an individual who purchases coverage outside the Individual Exchange if the individual or a dependent of the individual is:</text> <level label="i"> <text>a patient being treated on a regular basis by or at a provider; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="e"> <level label="1"> <text>A special enrollment period described in subsection (c)(2) or (d)(2) of this section shall:</text> <level label="i"> <text>be open for a period of 90 days; and</text> </level> <level label="ii"> <text>begin on the date the health care practitioner confirms the pregnancy.</text> </level> </level> <level label="2"> <text>A special enrollment period described in subsection (c)(3) or (d)(3) of this section shall:</text> <level label="i"> <text>be open for a period of 90 days; and</text> </level> <level label="ii"> <text>begin on:</text> <level label="1"> <text>the date of termination of the provider from the health benefit plan’s provider panel; or</text> </level> <level label="2"> <text>if the consumer did not receive notice of the termination before the termination date, the date of the notice of termination.</text> </level> </level> </level> </level> <level label="f"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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:</text> <level label="i"> <text>on the first day of the month following the date the health benefit plan was selected; or</text> </level> <level label="ii"> <text>on the first day of the month in which the termination of the provider on the health benefit plan’s provider panel became effective.</text> </level> </level> </level> <level label="g"> <level label="1"> <text>A health maintenance organization may:</text> <level label="i"> <text>limit the individuals who may apply for coverage to those who live or reside in the health maintenance organization’s service area; and</text> </level> <level label="ii"> <text>deny coverage to individuals if the health maintenance organization has demonstrated to the Commissioner that:</text> <level label="1"> <text>it will not have the capacity to deliver services adequately to any additional individuals because of its obligations to existing enrollees; and</text> </level> <level label="2"> <text>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.</text> </level> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>Paragraph (2) of this subsection does not:</text> <level label="i"> <text>limit the health maintenance organization’s ability to renew coverage already in force; or</text> </level> <level label="ii"> <text>relieve the health maintenance organization of the responsibility to renew coverage already in force.</text> </level> </level> </level> <level label="h"> <level label="1"> <text>A carrier may deny a health benefit plan to an individual if the carrier has demonstrated to the Commissioner that:</text> <level label="i"> <text>it does not have the financial reserves necessary to offer additional coverage; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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:</text> <level label="i"> <text>the 181st day after the date the carrier denies coverage; and</text> </level> <level label="ii"> <text>the date the carrier demonstrates to the Commissioner that the carrier has sufficient financial reserves to underwrite additional coverage.</text> </level> </level> <level label="3"> <text>Paragraph (2) of this subsection does not:</text> <level label="i"> <text>limit the carrier’s ability to renew coverage already in force; or</text> </level> <level label="ii"> <text>relieve the carrier of the responsibility to renew coverage already in force.</text> </level> </level> <level label="4"> <text>Health benefit plans offered after the time period described in paragraph (2) of this subsection are subject to the requirements of this section.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1317" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>A carrier shall accept all applicants who apply for coverage during the initial open enrollment period.</text> </level> <level label="c"> <text>If an application is received by a carrier during the initial open enrollment period, coverage for the applicant shall begin no later than:</text> <level label="1"> <text>January 1, 2014, if the application is received on or before December 15, 2013;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1318" title_number="15" title_name="Health Insurance" subtitle_number="13" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Individual Market Reforms"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Institution of higher education” has the meaning stated in the federal Higher Education Act of 1965.</text> </level> <level label="3"> <text>“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.</text> </level> <level label="4"> <text>“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:</text> <level label="i"> <text>is between the institution of higher education and a carrier;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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.</text> </level> </level> </level> <level label="b"> <text>A carrier that offers student health plans is not required to:</text> <level label="1"> <text>accept individuals who are not:</text> <level label="i"> <text>students; or</text> </level> <level label="ii"> <text>dependents of students covered under the student health plan;</text> </level> </level> <level label="2"> <text>establish open enrollment periods;</text> </level> <level label="3"> <text>establish effective dates that are based on a calendar year;</text> </level> <level label="4"> <text>offer health benefit plan contracts that are on a calendar year basis; or</text> </level> <level label="5"> <text>renew, or continue in force, coverage for individuals who are no longer students or dependents of students.</text> </level> </level> <level label="c"> <text>A student health plan is not subject to the requirement of a single risk pool under § 1312(c) of the Affordable Care Act.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>A student administrative health fee is not considered a cost–sharing requirement with respect to specified recommended preventive services.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1401" title_number="15" title_name="Health Insurance" subtitle_number="14" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“Association” or “bona fide association” means, with respect to health insurance coverage offered in this State, an association that:</text> <level label="1"> <text>has been actively in existence for at least 5 years;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>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;</text> </level> <level label="5"> <text>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</text> </level> <level label="6"> <text>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.</text> </level> </level> <level label="c"> <text>“Carrier” means a person that is:</text> <level label="1"> <text>an insurer that holds a certificate of authority in the State and provides health insurance in the State;</text> </level> <level label="2"> <text>a health maintenance organization that is licensed to operate in the State;</text> </level> <level label="3"> <text>a nonprofit health service plan that is licensed to operate in the State; or</text> </level> <level label="4"> <text>any other person or organization that provides health benefit plans subject to State insurance regulation.</text> </level> </level> <level label="d"> <text>“Church plan” means a plan as defined under § 3(33) of the Employee Retirement Income Security Act of 1974.</text> </level> <level label="e"> <text>“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.</text> </level> <level label="f"> <text>“Enrollment date” means the date on which:</text> <level label="1"> <text>an individual enrolls in a health benefit plan; or</text> </level> <level label="2"> <text>the first day of the waiting period before which the individual may enroll.</text> </level> </level> <level label="g"> <text>“Governmental plan” means a plan as defined in § 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan.</text> </level> <level label="h"> <level label="1"> <text>“Health benefit plan” means any:</text> <level label="i"> <text>hospital or medical policy, including those issued under multiple employer trusts or associations located in Maryland or any other state covering Maryland residents;</text> </level> <level label="ii"> <text>policy or contract issued by a nonprofit health service plan that covers Maryland residents; or</text> </level> <level label="iii"> <text>health maintenance organization subscriber or group master contract.</text> </level> </level> <level label="2"> <text>“Health benefit plan” does not include:</text> <level label="i"> <text>one or more, or any combination of the following:</text> <level label="1"> <text>coverage only for accident or disability income insurance;</text> </level> <level label="2"> <text>coverage issued as a supplement to liability insurance;</text> </level> <level label="3"> <text>liability insurance, including general liability insurance and automobile liability insurance;</text> </level> <level label="4"> <text>workers’ compensation or similar insurance;</text> </level> <level label="5"> <text>automobile medical payment insurance;</text> </level> <level label="6"> <text>credit–only insurance;</text> </level> <level label="7"> <text>coverage for on–site medical clinics; and</text> </level> <level label="8"> <text>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;</text> </level> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>limited scope dental or vision benefits;</text> </level> <level label="2"> <text>benefits for long–term care, nursing home care, home health care, community–based care, or any combination of these benefits; and</text> </level> <level label="3"> <text>such other similar, limited benefits as are specified in federal regulations issued under the federal Health Insurance Portability and Accountability Act;</text> </level> </level> <level label="iii"> <text>the following benefits if offered as independent, noncoordinated benefits:</text> <level label="1"> <text>coverage only for a specified disease or illness; and</text> </level> <level label="2"> <text>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</text> </level> </level> <level label="iv"> <text>the following benefits if offered as a separate insurance policy:</text> <level label="1"> <text>Medicare supplemental health insurance (as defined under § 1882(g)(1) of the Social Security Act);</text> </level> <level label="2"> <text>coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and</text> </level> <level label="3"> <text>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).</text> </level> </level> </level> </level> <level label="i"> <text>“Health status–related factor” means a factor related to:</text> <level label="1"> <text>health status;</text> </level> <level label="2"> <text>medical condition;</text> </level> <level label="3"> <text>claims experience;</text> </level> <level label="4"> <text>receipt of health care;</text> </level> <level label="5"> <text>medical history;</text> </level> <level label="6"> <text>genetic information;</text> </level> <level label="7"> <text>evidence of insurability including conditions arising out of acts of domestic violence; or</text> </level> <level label="8"> <text>disability.</text> </level> </level> <level label="j"> <text>“Late enrollee” means a member, subscriber, or dependent who enrolls in a group health benefit plan other than during:</text> <level label="1"> <text>the first period in which the individual is eligible to enroll under the plan; or</text> </level> <level label="2"> <text>a special enrollment period.</text> </level> </level> <level label="k"> <text>“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.</text> </level> <level label="l"> <text>“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.</text> </level> <level label="m"> <text>“Secretary” means the Secretary of the federal Department of Health and Human Services.</text> </level> <level label="n"> <text>“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.</text> </level> <level label="o"> <text>“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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1402" title_number="15" title_name="Health Insurance" subtitle_number="14" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms"> <level label="a"> <text>Subject to subsection (b) of this section, this subtitle applies to all carriers in connection with group health benefit plans.</text> </level> <level label="b"> <text>This subtitle does not apply to policies issued under Subtitle 12 of this title.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1406" title_number="15" title_name="Health Insurance" subtitle_number="14" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>Subsection (a) of this section does not:</text> <level label="1"> <text>require a carrier to provide particular benefits other than those provided under the terms of the particular health benefit plan; or</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>Rules for eligibility to enroll under a plan include rules defining any applicable waiting periods for enrollment.</text> </level> <level label="d"> <text>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:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>the employee’s or dependent’s coverage described in item (1) of this subsection:</text> <level label="i"> <text>was under a COBRA continuation provision, and the coverage under that provision was exhausted; or</text> </level> <level label="ii"> <text>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</text> </level> </level> <level label="4"> <text>under the terms of the plan, the employee requests enrollment not later than 30 days after:</text> <level label="i"> <text>the date of exhaustion of coverage described in item (3)(i) of this subsection; or</text> </level> <level label="ii"> <text>termination of coverage or termination of employer contributions described in item (3)(ii) of this subsection.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1406.1" title_number="15" title_name="Health Insurance" subtitle_number="14" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms"> <level label="a"> <text>In this section, “eligible employee” means:</text> <level label="1"> <text>a participant under the group health benefit plan; or</text> </level> <level label="2"> <text>an individual who:</text> <level label="i"> <text>has met any waiting period applicable to becoming a participant under the group health benefit plan;</text> </level> <level label="ii"> <text>is eligible to be enrolled under the plan; and</text> </level> <level label="iii"> <text>is not a participant in the group health benefit plan because of failure to enroll during a previous enrollment period.</text> </level> </level> </level> <level label="b"> <text>This section applies if a group health benefit plan makes coverage available to dependents of an eligible employee.</text> </level> <level label="c"> <text>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:</text> <level label="1"> <text>an individual who becomes a dependent of an eligible employee through marriage, birth, adoption, or placement for adoption;</text> </level> <level label="2"> <text>an eligible employee who acquires a new dependent through marriage, birth, adoption, or placement for adoption; and</text> </level> <level label="3"> <text>the spouse of an eligible employee at the birth or adoption of a child, provided the spouse is otherwise eligible for coverage.</text> </level> </level> <level label="d"> <text>An eligible employee may not enroll a dependent during a special enrollment period unless the eligible employee:</text> <level label="1"> <text>is enrolled under the health benefit plan; or</text> </level> <level label="2"> <text>applies for coverage for the eligible employee during the same special enrollment period.</text> </level> </level> <level label="e"> <text>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:</text> <level label="1"> <text>the date dependent coverage is made available; or</text> </level> <level label="2"> <text>the date of the marriage, birth, adoption, or placement for adoption, whichever is applicable.</text> </level> </level> <level label="f"> <text>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:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>in the case of a dependent’s birth, as of the date of the dependent’s birth; and</text> </level> <level label="3"> <text>in the case of a dependent’s adoption or placement for adoption, the date of adoption or placement for adoption, whichever occurs first.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1407" title_number="15" title_name="Health Insurance" subtitle_number="14" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1408" title_number="15" title_name="Health Insurance" subtitle_number="14" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms"> <text>A carrier shall renew group health benefit plans at the option of the policyholder or plan sponsor, except in any of the following cases:</text> <level label="1"> <text>for nonpayment of the required premium;</text> </level> <level label="2"> <text>where the policyholder or plan sponsor has performed an act or practice that constitutes fraud;</text> </level> <level label="3"> <text>where the policyholder or plan sponsor has made an intentional misrepresentation of material fact under the terms of the coverage;</text> </level> <level label="4"> <text>where the policyholder or plan sponsor has failed to comply with a material plan provision relating to the employer contributions or group participation rules;</text> </level> <level label="5"> <text>where the carrier elects not to renew all group health benefit plans in the State;</text> </level> <level label="6"> <text>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;</text> </level> <level label="7"> <text>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</text> </level> <level label="8"> <text>the carrier makes an election under § 15–1409 of this subtitle.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1409" title_number="15" title_name="Health Insurance" subtitle_number="14" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>A carrier that elects not to renew all of a particular product in the State shall:</text> <level label="1"> <text>provide notice of the nonrenewal at least 90 days before the date of the nonrenewal to each affected:</text> <level label="i"> <text>policyholder;</text> </level> <level label="ii"> <text>plan sponsor;</text> </level> <level label="iii"> <text>participant; and</text> </level> <level label="iv"> <text>beneficiary;</text> </level> </level> <level label="2"> <text>offer to each affected plan sponsor the option to purchase any other health insurance coverage currently being offered by the carrier; and</text> </level> <level label="3"> <text>act uniformly without regard to the claims experience of any affected plan sponsor, or any health status–related factor of any affected individual.</text> </level> </level> <level label="c"> <text>A carrier may elect not to renew all group health benefit plans in the State.</text> </level> <level label="d"> <text>When a carrier elects not to renew all group health benefit plans in the State, the carrier:</text> <level label="1"> <text>shall give notice of its decision to the affected individuals at least 180 days before the effective date of nonrenewal;</text> </level> <level label="2"> <text>at least 30 working days before that notice, shall give notice to the Commissioner; and</text> </level> <level label="3"> <text>may not write new business for groups in the State for a 5–year period beginning on the date of notice to the Commissioner.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>A carrier may make a uniform modification of coverage for a product only at the time of renewal of a health benefit plan.</text> </level> <level label="g"> <text>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).</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1410" title_number="15" title_name="Health Insurance" subtitle_number="14" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms"> <level label="a"> <text>In this section, “plan year” has the meaning stated in § 15–1201 of this title.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1411" title_number="15" title_name="Health Insurance" subtitle_number="14" subtitle_name="Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“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.</text> </level> <level label="3"> <text>“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.</text> </level> <level label="4"> <text>“Large employer” means an employer that is not a small employer as defined in § 31–101 of this article.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1501" title_number="15" title_name="Health Insurance" subtitle_number="15" subtitle_name="Mandated Health Insurance Services Evaluation"> <level label="a"> <level label="1"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Commission” means the Maryland Health Care Commission.</text> </level> <level label="3"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“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.</text> </level> </level> </level> <level label="b"> <text>This subtitle does not affect the ability of the General Assembly to enact legislation on mandated health insurance services.</text> </level> <level label="c"> <level label="1"> <text>The Commission shall assess the social, medical, and financial impacts of a proposed mandated health insurance service.</text> </level> <level label="2"> <text>In assessing a proposed mandated health insurance service and to the extent that information is available, the Commission shall consider:</text> <level label="i"> <text>social impacts, including:</text> <level label="1"> <text>the extent to which the service is generally utilized by a significant portion of the population;</text> </level> <level label="2"> <text>the extent to which the insurance coverage is already generally available;</text> </level> <level label="3"> <text>if coverage is not generally available, the extent to which the lack of coverage results in individuals avoiding necessary health care treatments;</text> </level> <level label="4"> <text>if coverage is not generally available, the extent to which the lack of coverage results in unreasonable financial hardship;</text> </level> <level label="5"> <text>the level of public demand for the service;</text> </level> <level label="6"> <text>the level of public demand for insurance coverage of the service;</text> </level> <level label="7"> <text>the level of interest of collective bargaining agents in negotiating privately for inclusion of this coverage in group contracts; and</text> </level> <level label="8"> <text>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;</text> </level> </level> <level label="ii"> <text>medical impacts, including:</text> <level label="1"> <text>the extent to which the service is generally recognized by the medical community as being effective and efficacious in the treatment of patients;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>the extent to which the service is generally available and utilized by treating physicians; and</text> </level> </level> <level label="iii"> <text>financial impacts, including:</text> <level label="1"> <text>the extent to which the coverage will increase or decrease the cost of the service;</text> </level> <level label="2"> <text>the extent to which the coverage will increase the appropriate use of the service;</text> </level> <level label="3"> <text>the extent to which the mandated service will be a substitute for a more expensive service;</text> </level> <level label="4"> <text>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;</text> </level> <level label="5"> <text>the impact of this coverage on the total cost of health care; and</text> </level> <level label="6"> <text>the impact of all mandated health insurance services on employers’ ability to purchase health benefits policies meeting their employees’ needs.</text> </level> </level> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1502" title_number="15" title_name="Health Insurance" subtitle_number="15" subtitle_name="Mandated Health Insurance Services Evaluation"> <level label="a"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>The evaluation shall include:</text> <level label="i"> <text>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:</text> <level label="1"> <text>under a typical group and individual health benefit plan in the State;</text> </level> <level label="2"> <text>under the State employee health benefit plan; and</text> </level> <level label="3"> <text>under the Comprehensive Standard Health Benefit Plan;</text> </level> </level> <level label="ii"> <text>an assessment of the degree to which existing mandated health insurance services are covered in self–funded plans; and</text> </level> <level label="iii"> <text>a comparison of mandated health insurance services provided by the State with those provided in Delaware, the District of Columbia, Pennsylvania, and Virginia.</text> </level> </level> <level label="3"> <text>The comparison described in paragraph (2)(iii) of this subsection shall include:</text> <level label="i"> <text>the number of mandated health insurance services;</text> </level> <level label="ii"> <text>the type of mandated health insurance services;</text> </level> <level label="iii"> <text>the level and extent of coverage for each mandated health insurance service; and</text> </level> <level label="iv"> <text>the financial impact of differences in levels of coverage for each mandated health insurance service.</text> </level> </level> <level label="4"> <text>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.</text> </level> </level> <level label="b"> <text>The General Assembly may consider the information provided under subsection (a) of this section in determining:</text> <level label="1"> <text>whether to enact proposed mandated health insurance services; and</text> </level> <level label="2"> <text>whether to repeal existing mandated health insurance services.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1601" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“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.</text> </level> <level label="c"> <text>“Beneficiary” means an individual who receives prescription drug coverage or benefits from a purchaser.</text> </level> <level label="d"> <level label="1"> <text>“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:</text> <level label="i"> <text>provides prescription drug coverage or benefits in the State; and</text> </level> <level label="ii"> <text>enters into an agreement with a pharmacy benefits manager for the provision of pharmacy benefits management services.</text> </level> </level> <level label="2"> <text>“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.</text> </level> </level> <level label="e"> <text>“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.</text> </level> <level label="f"> <text>“Contracted pharmacy” means a pharmacy that participates in the network of a pharmacy benefits manager through a contract with:</text> <level label="1"> <text>the pharmacy benefits manager; or</text> </level> <level label="2"> <text>a pharmacy services administration organization or a group purchasing organization.</text> </level> </level> <level label="g"> <text>“ERISA” has the meaning stated in § 8–301 of this article.</text> </level> <level label="h"> <text>“Formulary” means a list of prescription drugs used by a purchaser.</text> </level> <level label="i"> <level label="1"> <text>“Manufacturer payments” means any compensation or remuneration a pharmacy benefits manager receives from or on behalf of a pharmaceutical manufacturer.</text> </level> <level label="2"> <text>“Manufacturer payments” includes:</text> <level label="i"> <text>payments received in accordance with agreements with pharmaceutical manufacturers for formulary placement and, if applicable, drug utilization;</text> </level> <level label="ii"> <text>rebates, regardless of how categorized;</text> </level> <level label="iii"> <text>market share incentives;</text> </level> <level label="iv"> <text>commissions;</text> </level> <level label="v"> <text>fees under products and services agreements;</text> </level> <level label="vi"> <text>any fees received for the sale of utilization data to a pharmaceutical manufacturer; and</text> </level> <level label="vii"> <text>administrative or management fees.</text> </level> </level> <level label="3"> <text>“Manufacturer payments” does not include purchase discounts based on invoiced purchase terms.</text> </level> </level> <level label="j"> <text>“Nonprofit health maintenance organization” has the meaning stated in § 6–121(a) of this article.</text> </level> <level label="k"> <text>“Nonresident pharmacy” has the meaning stated in § 12–403 of the Health Occupations Article.</text> </level> <level label="l"> <text>“Participating pharmacy contract” means a contract filed with the Commissioner in accordance with § 15–1628(b) of this subtitle.</text> </level> <level label="m"> <text>“Pharmacist” has the meaning stated in § 12–101 of the Health Occupations Article.</text> </level> <level label="n"> <text>“Pharmacy” has the meaning stated in § 12–101 of the Health Occupations Article.</text> </level> <level label="o"> <text>“Pharmacy and therapeutics committee” means a committee established by a pharmacy benefits manager to:</text> <level label="1"> <text>objectively appraise and evaluate prescription drugs; and</text> </level> <level label="2"> <text>make recommendations to a purchaser regarding the selection of drugs for the purchaser’s formulary.</text> </level> </level> <level label="p"> <level label="1"> <text>“Pharmacy benefits management services” means:</text> <level label="i"> <text>the procurement of prescription drugs at a negotiated rate for dispensation within the State to beneficiaries;</text> </level> <level label="ii"> <text>the administration or management of prescription drug coverage provided by a purchaser for beneficiaries; and</text> </level> <level label="iii"> <text>any of the following services provided with regard to the administration of prescription drug coverage:</text> <level label="1"> <text>mail service pharmacy;</text> </level> <level label="2"> <text>claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to beneficiaries;</text> </level> <level label="3"> <text>clinical formulary development and management services;</text> </level> <level label="4"> <text>rebate contracting and administration;</text> </level> <level label="5"> <text>patient compliance, therapeutic intervention, and generic substitution programs; or</text> </level> <level label="6"> <text>disease management programs.</text> </level> </level> </level> <level label="2"> <text>“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:</text> <level label="i"> <text>is provided solely to a member of the nonprofit health maintenance organization; and</text> </level> <level label="ii"> <text>is furnished through the internal pharmacy operations of the nonprofit health maintenance organization.</text> </level> </level> </level> <level label="q"> <text>“Pharmacy benefits manager” means a person that performs pharmacy benefits management services.</text> </level> <level label="r"> <text>“Proprietary information” means:</text> <level label="1"> <text>a trade secret;</text> </level> <level label="2"> <text>confidential commercial information; or</text> </level> <level label="3"> <text>confidential financial information.</text> </level> </level> <level label="s"> <text>“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:</text> <level label="1"> <text>provides prescription drug coverage or benefits in the State; and</text> </level> <level label="2"> <text>enters into an agreement with a pharmacy benefits manager for the provision of pharmacy benefits management services.</text> </level> </level> <level label="t"> <text>“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.</text> </level> <level label="u"> <level label="1"> <text>“Therapeutic interchange” means any change from one prescription drug to another.</text> </level> <level label="2"> <text>“Therapeutic interchange” does not include:</text> <level label="i"> <text>a change initiated pursuant to a drug utilization review;</text> </level> <level label="ii"> <text>a change initiated for patient safety reasons;</text> </level> <level label="iii"> <text>a change required due to market unavailability of the currently prescribed drug;</text> </level> <level label="iv"> <text>a change from a brand name drug to a generic drug in accordance with § 12–504 of the Health Occupations Article; or</text> </level> <level label="v"> <text>a change required for coverage reasons because the originally prescribed drug is not covered by the beneficiary’s formulary or plan.</text> </level> </level> </level> <level label="v"> <text>“Therapeutic interchange solicitation” means any communication by a pharmacy benefits manager for the purpose of requesting a therapeutic interchange.</text> </level> <level label="w"> <text>“Trade secret” has the meaning stated in § 11–1201 of the Commercial Law Article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1604" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>An applicant for registration shall:</text> <level label="1"> <text>file with the Commissioner an application on the form that the Commissioner provides; and</text> </level> <level label="2"> <text>pay to the Commissioner a registration fee set by the Commissioner.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1605" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>A pharmacy benefits manager registration expires on the second September 30 after its effective date unless it is renewed as provided under this section.</text> </level> <level label="b"> <text>A pharmacy benefits manager may renew its registration for an additional 2–year term, if the pharmacy benefits manager:</text> <level label="1"> <text>otherwise is entitled to be registered;</text> </level> <level label="2"> <text>files with the Commissioner a renewal application on the form that the Commissioner requires; and</text> </level> <level label="3"> <text>pays to the Commissioner a renewal fee set by the Commissioner.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1606" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>A carrier may not enter into an agreement with a pharmacy benefits manager that has not registered with the Commissioner. </text> </section> <section article="gin" article_name="Insurance" number="15-1607" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>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:</text> <level label="1"> <text>makes a material misstatement or misrepresentation in an application for registration;</text> </level> <level label="2"> <text>fraudulently or deceptively obtains or attempts to obtain a registration;</text> </level> <level label="3"> <text>in connection with the administration of pharmacy benefits management services, commits fraud or engages in illegal or dishonest activities; or</text> </level> <level label="4"> <text>violates any provision of this part or a regulation adopted under this part.</text> </level> </level> <level label="b"> <text>This section does not limit any other regulatory authority of the Commissioner under this article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1608" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>A pharmacy benefits manager shall maintain adequate books and records about each purchaser for which the pharmacy benefits manager provides pharmacy benefits management services:</text> <level label="1"> <text>in accordance with prudent standards of record keeping;</text> </level> <level label="2"> <text>for the duration of the agreement between the pharmacy benefits manager and the purchaser; and</text> </level> <level label="3"> <text>for 3 years after the pharmacy benefits manager ceases to provide pharmacy benefits management services for the purchaser.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1609" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>Whenever the Commissioner considers it advisable, the Commissioner may examine the affairs, transactions, accounts, and records of a registered pharmacy benefits manager.</text> </level> <level label="b"> <text>The examination shall be conducted in accordance with § 2–207 of this article.</text> </level> <level label="c"> <text>The expense of the examination shall be paid in accordance with § 2–208 of this article.</text> </level> <level label="d"> <text>The reports of the examination and investigation shall be issued in accordance with § 2–209 of this article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1610" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>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. </text> </section> <section article="gin" article_name="Insurance" number="15-1611" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.</text> </level> <level label="b"> <text>A pharmacy benefits manager may not prohibit a pharmacy or pharmacist from:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="c"> <text>This section may not be construed to alter the requirements for a therapeutic interchange under §§ 15–1633.1 through 15–1639 of this subtitle.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1611.1" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>the pharmacy benefits manager or a corporate affiliate of the pharmacy benefits manager has an ownership interest in the pharmacy or entity; or</text> </level> <level label="2"> <text>the pharmacy or entity has an ownership interest in the pharmacy benefits manager or a corporate affiliate of the pharmacy benefits manager.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1611.2" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Covered entity” has the meaning stated in § 602 of the federal Veterans Health Care Act of 1992.</text> </level> <level label="3"> <text>“Pharmacies or pharmacists that participate in the 340B Program” means:</text> <level label="i"> <text>a pharmacy owned or operated by a covered entity that is eligible to or is actively participating in the 340B Program; or</text> </level> <level label="ii"> <text>a pharmacy or pharmacist under contract with a covered entity to dispense drugs purchased under the 340B Program to patients of the covered entity.</text> </level> </level> <level label="4"> <text>“340B Program” means the drug pricing program established under § 602 of the federal Veterans Health Care Act of 1992.</text> </level> </level> <level label="b"> <text>A pharmacy benefits manager shall:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="c"> <text>A pharmacy benefits manager may not:</text> <level label="1"> <text>transfer the 340B Program savings from a pharmacy or pharmacist that participates in the 340B Program to a pharmacy benefits manager;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>refuse to cover the prescription drugs purchased under the 340B Program;</text> </level> <level label="4"> <text>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;</text> </level> <level label="5"> <text>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;</text> </level> <level label="6"> <text>impose different fees, chargebacks, or other adjustments on pharmacies or pharmacists based on whether a pharmacy or pharmacist participates in the 340B Program;</text> </level> <level label="7"> <text>modify a beneficiary’s copayment on the basis of whether a pharmacy or pharmacist participates in the 340B Program;</text> </level> <level label="8"> <text>establish or set network adequacy requirements based on whether a pharmacy or pharmacist participates in the 340B Program; or</text> </level> <level label="9"> <text>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.</text> </level> </level> <level label="d"> <text>A pharmacy benefits manager may not base formulary or prescription drug coverage decisions on:</text> <level label="1"> <text>the price of the prescription drug under the 340B Program; or</text> </level> <level label="2"> <text>whether the dispensing pharmacy or pharmacist participates in the 340B Program.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1612" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.</text> </level> <level label="b"> <text>This section does not apply to reimbursement:</text> <level label="1"> <text>except as provided in § 15–847.2 of this title, for specialty drugs;</text> </level> <level label="2"> <text>for mail order drugs; or</text> </level> <level label="3"> <text>to a chain pharmacy with more than 15 stores or a pharmacist who is an employee of the chain pharmacy.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1613" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1614" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <level label="1"> <text>A pharmacy and therapeutics committee shall:</text> <level label="i"> <text>include clinical specialists that represent the needs of a purchaser’s beneficiaries; and</text> </level> <level label="ii"> <text>include at least one practicing pharmacist and one practicing physician who are independent of any developer or manufacturer of prescription drugs.</text> </level> </level> <level label="2"> <text>A majority of the members of a pharmacy and therapeutics committee shall be practicing physicians or practicing pharmacists.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1615" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>A pharmacy benefits manager may not require a pharmacist to participate on its pharmacy and therapeutics committee. </text> </section> <section article="gin" article_name="Insurance" number="15-1616" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1617" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>A pharmacy benefits manager shall ensure that its pharmacy and therapeutics committee has:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1618" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1619" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>The Commissioner may adopt regulations to implement this part.</text> </section> <section article="gin" article_name="Insurance" number="15-1622" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1623" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>Before entering into a contract with a purchaser, a pharmacy benefits manager:</text> <level label="1"> <text>as applicable, shall inform the purchaser that the pharmacy benefits manager may:</text> <level label="i"> <text>solicit and receive manufacturer payments;</text> </level> <level label="ii"> <text>pass through or retain the manufacturer payments depending on the contract terms with a purchaser;</text> </level> <level label="iii"> <text>sell aggregate utilization information; and</text> </level> <level label="iv"> <text>share aggregate utilization information with other entities; and</text> </level> </level> <level label="2"> <text>shall offer to provide to the purchaser a report that contains the:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>amount of all manufacturer payments earned by the pharmacy benefits manager.</text> </level> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1624" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>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:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>total prescription drug expenditures applicable to the purchaser;</text> </level> <level label="3"> <text>total manufacturer payments earned by the pharmacy benefits manager during the applicable reporting period; and</text> </level> <level label="4"> <text>total rebates applicable to the purchaser during the applicable reporting period.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>its current best estimate of the amount of each item; and</text> </level> <level label="2"> <text>an updated report containing the exact amount of each item immediately after it becomes available.</text> </level> </level> <level label="c"> <level label="1"> <text>A pharmacy benefits manager shall provide the information described in subsections (a) and (b) of this section if requested by the purchaser.</text> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1625" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1628" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <level label="1"> <text>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:</text> <level label="i"> <text>the applicable terms, conditions, and reimbursement rates;</text> </level> <level label="ii"> <text>the process and procedures for verifying pharmacy benefits and beneficiary eligibility;</text> </level> <level label="iii"> <text>the dispute resolution and audit appeals process; and</text> </level> <level label="iv"> <text>the process and procedures for verifying the prescription drugs included on the formularies used by the pharmacy benefits manager.</text> </level> </level> <level label="2"> <level label="i"> <text>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.</text> </level> <level label="ii"> <text>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:</text> <level label="1"> <text>require a pharmacy or pharmacist to renew credentialing more frequently than once every 3 years; or</text> </level> <level label="2"> <text>charge a pharmacy or pharmacist a fee for the initial credentialing or renewing credentialing.</text> </level> </level> </level> </level> <level label="b"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1628.1" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <level label="1"> <text>In this section the following words have the meanings indicated.</text> </level> <level label="2"> <text>“Drug shortage list” means a list of drug products listed on the federal Food and Drug Administration’s Drug Shortages website.</text> </level> <level label="3"> <level label="i"> <text>“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.</text> </level> <level label="ii"> <text>“Maximum allowable cost” does not include dispensing fees.</text> </level> </level> <level label="4"> <text>“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.</text> </level> </level> <level label="b"> <text>In each participating pharmacy contract, the pharmacy benefits manager shall include the sources used to determine maximum allowable cost pricing.</text> </level> <level label="c"> <text>A pharmacy benefits manager shall:</text> <level label="1"> <text>update its pricing information at least every 7 days;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <text>remain consistent with pricing changes;</text> </level> <level label="ii"> <text>remove from the list drugs that no longer meet the requirements of subsection (e) of this section; and</text> </level> <level label="iii"> <text>reflect the current availability of drugs in the marketplace.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> <level label="e"> <text>Before placing a prescription drug on a maximum allowable cost list, a pharmacy benefits manager shall ensure that:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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</text> </level> </level> <level label="3"> <text>the drug is not obsolete, temporarily unavailable, or listed on a drug shortage list as currently in shortage.</text> </level> </level> <level label="f"> <text>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:</text> <level label="1"> <text>a requirement that an appeal be filed by the contract pharmacy no later than 21 days after the date of the initial adjudicated claim;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>a requirement that a pharmacy benefits manager make available on its website information about the appeal process, including:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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;</text> </level> </level> <level label="4"> <text>a requirement that a pharmacy benefits manager provide:</text> <level label="i"> <text>a reason for any appeal denial;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>the mathematical calculation used to determine the maximum allowable cost; and</text> </level> </level> <level label="5"> <text>if an appeal is upheld, a requirement that a pharmacy benefits manager:</text> <level label="i"> <text>for the appealing pharmacy:</text> <level label="1"> <text>adjust the maximum allowable cost for the drug as of the date of the original claim for payment; and</text> </level> <level label="2"> <text>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:</text> </level> <level label="A"> <text>for the original claim, in the first remittance to the pharmacy after the date the appeal was determined; and</text> </level> <level label="B"> <text>for subsequent and similar claims under similarly applicable contracts, in the second remittance to the pharmacy after the date the appeal was determined; and</text> </level> </level> <level label="ii"> <text>for a similarly situated contracted pharmacy in the State:</text> <level label="1"> <text>adjust the maximum allowable cost for the drug as of the date the appeal was determined; and</text> </level> <level label="2"> <text>provide notice to the pharmacy or pharmacy’s contracted agent that:</text> </level> <level label="A"> <text>an appeal has been upheld; and</text> </level> <level label="B"> <text>without filing a separate appeal, the pharmacy or the pharmacy’s contracted agent may reverse and rebill a similar claim.</text> </level> </level> </level> </level> <level label="g"> <text>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.</text> </level> <level label="h"> <text>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.</text> </level> <level label="i"> <level label="1"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>All information and data collected by the Commissioner during a review:</text> <level label="i"> <text>is considered to be confidential and proprietary information; and</text> </level> <level label="ii"> <text>is not subject to disclosure under the Public Information Act.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1628.2" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>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:</text> <level label="1"> <text>a requirement that an appeal be filed by the contract pharmacy not later than 21 days after:</text> <level label="i"> <text>the date a direct or indirect remuneration fee is charged; or</text> </level> <level label="ii"> <text>another date as determined by the Commissioner;</text> </level> </level> <level label="2"> <text>a requirement that a pharmacy benefits manager make available on its website information about the appeal process, including:</text> <level label="i"> <text>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;</text> </level> <level label="ii"> <text>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</text> </level> <level label="iii"> <text>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;</text> </level> </level> <level label="3"> <text>a requirement that a pharmacy benefits manager provide:</text> <level label="i"> <text>a reason for any appeal denial; and</text> </level> <level label="ii"> <text>the mathematical calculation used to determine the amount of reimbursement; and</text> </level> </level> <level label="4"> <text>if an appeal is upheld, a requirement that a pharmacy benefits manager:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>provide notice to the pharmacy or pharmacy’s contracted agent that an appeal has been upheld.</text> </level> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>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:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>All information and data collected by the Commissioner during a review:</text> <level label="i"> <text>is considered to be confidential and proprietary information; and</text> </level> <level label="ii"> <text>is not subject to disclosure under the Public Information Act.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1628.3" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1629" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.</text> </level> <level label="b"> <text>This section does not apply to an audit that involves probable or potential fraud or willful misrepresentation by a pharmacy or pharmacist.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <level label="1"> <text>A pharmacy benefits manager may conduct an audit through an auditing entity.</text> </level> <level label="2"> <text>The Commissioner may adopt regulations to carry out this subsection.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>When conducting an audit, a pharmacy benefits manager shall:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>employ the services of a pharmacist if the audit requires the clinical or professional judgment of a pharmacist;</text> </level> <level label="3"> <text>allow its auditors to enter the prescription area of a pharmacy only when accompanied by or authorized by a member of the pharmacy staff;</text> </level> <level label="4"> <text>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;</text> </level> <level label="5"> <text>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:</text> <level label="i"> <text>written; or</text> </level> <level label="ii"> <text>transmitted electronically or by any other means of communication authorized by contract between the pharmacy and the pharmacy benefits manager;</text> </level> </level> <level label="6"> <text>accept a completed cash register transaction to serve as proof of delivery or pickup for a pharmacy customer unless there is contradictory information;</text> </level> <level label="7"> <text>audit each pharmacy and pharmacist under the same standards and parameters as other similarly situated pharmacies or pharmacists audited by the pharmacy benefits manager;</text> </level> <level label="8"> <text>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;</text> </level> <level label="9"> <text>deliver the preliminary audit report to the pharmacy or pharmacist within 120 calendar days after the completion of the audit, with reasonable extensions allowed;</text> </level> <level label="10"> <text>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</text> </level> <level label="11"> <text>deliver the final audit report to the pharmacy or pharmacist:</text> <level label="i"> <text>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</text> </level> <level label="ii"> <text>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.</text> </level> </level> </level> <level label="g"> <text>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:</text> <level label="1"> <text>the preliminary audit report is delivered if the pharmacy or pharmacist does not request an internal appeal under subsection (m) of this section; or</text> </level> <level label="2"> <text>the conclusion of the internal appeals process under subsection (m) of this section if the pharmacy or pharmacist requests an internal appeal.</text> </level> </level> <level label="h"> <text>During an audit, a pharmacy benefits manager may not disrupt the provision of services to the customers of a pharmacy.</text> </level> <level label="i"> <level label="1"> <text>A pharmacy benefits manager may not:</text> <level label="i"> <text>use the accounting practice of extrapolation to calculate overpayments or underpayments;</text> </level> <level label="ii"> <text>except as provided in paragraph (2) of this subsection:</text> <level label="1"> <text>share information from an audit with another pharmacy benefits manager; or</text> </level> <level label="2"> <text>use information from an audit conducted by another pharmacy benefits manager;</text> </level> </level> <level label="iii"> <text>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;</text> </level> <level label="iv"> <text>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</text> </level> <level label="v"> <text>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.</text> </level> </level> <level label="2"> <text>Paragraph (1)(ii) of this subsection does not apply to the sharing of information:</text> <level label="i"> <text>required by federal or State law;</text> </level> <level label="ii"> <text>in connection with an acquisition or merger involving the pharmacy benefits manager; or</text> </level> <level label="iii"> <text>at the payor’s request or under the terms of the agreement between the pharmacy benefits manager and the payor.</text> </level> </level> </level> <level label="j"> <text>A pharmacy benefits manager or purchaser may not audit more than 125 prescriptions during a desk or site audit.</text> </level> <level label="k"> <text>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.</text> </level> <level label="l"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>Notwithstanding paragraph (2) of this subsection, claims remain subject to recoupment of overpayment or payment of any discovered underpayment by the pharmacy benefits manager.</text> </level> </level> <level label="m"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="n"> <level label="1"> <text>A pharmacy benefits manager may not recoup by setoff any money for an overpayment or denial of a claim until:</text> <level label="i"> <text>the pharmacy or pharmacist has an opportunity to review the pharmacy benefits manager’s findings; and</text> </level> <level label="ii"> <text>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.</text> </level> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> </level> <level label="o"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> </level> <level label="p"> <level label="1"> <text>The pharmacy benefits manager shall give the pharmacy or pharmacist the option to provide requested audit documentation by postal mail, e–mail, or facsimile.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> </level> <level label="q"> <level label="1"> <text>The Commissioner may adopt regulations regarding:</text> <level label="i"> <text>the documentation that may be requested during an audit; and</text> </level> <level label="ii"> <text>the process a pharmacy benefits manager may use to conduct an audit.</text> </level> </level> <level label="2"> <text>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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1630" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.</text> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1631" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>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:</text> <level label="1"> <text>the claim was fraudulent;</text> </level> <level label="2"> <text>the pharmacy or pharmacist had been reimbursed for the claim previously; or</text> </level> <level label="3"> <text>the services reimbursed were not rendered by the pharmacy or pharmacist.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1633" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-1633.1" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>A pharmacy benefits manager or its agent may not request a therapeutic interchange unless:</text> <level label="1"> <text>the proposed therapeutic interchange is for medical reasons that benefit the beneficiary; or</text> </level> <level label="2"> <text>the proposed therapeutic interchange will result in financial savings and benefits to the purchaser or the beneficiary.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1634" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>In any therapeutic interchange solicitation, the following shall be disclosed to the prescriber:</text> <level label="1"> <text>that a therapeutic interchange is being solicited;</text> </level> <level label="2"> <text>the circumstances under which the originally prescribed drug will be covered by the purchaser;</text> </level> <level label="3"> <text>the difference in copayments or coinsurance to be paid by the beneficiary to obtain the proposed drug;</text> </level> <level label="4"> <text>the circumstances and extent to which health care costs related to the therapeutic interchange will be compensated; and</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1635" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>If a therapeutic interchange occurs, the pharmacy benefits manager or its agent shall:</text> <level label="1"> <text>disclose to the beneficiary, orally or in writing:</text> <level label="i"> <text>that the pharmacy benefits manager or its agent requested a therapeutic interchange by contacting the beneficiary’s prescriber;</text> </level> <level label="ii"> <text>the prescriber approved the therapeutic interchange;</text> </level> <level label="iii"> <text>the names of the originally prescribed drug and the drug dispensed pursuant to the therapeutic interchange;</text> </level> <level label="iv"> <text>the difference in copayments or coinsurance to be paid by the beneficiary to obtain the drug dispensed pursuant to the therapeutic interchange;</text> </level> <level label="v"> <text>the circumstances under which the originally prescribed drug will be covered;</text> </level> <level label="vi"> <text>the circumstances under and the extent to which health care costs related to the therapeutic interchange will be compensated; and</text> </level> <level label="vii"> <text>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</text> </level> </level> <level label="2"> <text>include with the prescription drug dispensed:</text> <level label="i"> <text>a patient package insert about potential side effects; and</text> </level> <level label="ii"> <text>a toll–free telephone number to communicate with the pharmacy benefits manager.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1636" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>If a therapeutic interchange is reversed, the pharmacy benefits manager or its agent shall:</text> <level label="1"> <text>obtain a prescription for and dispense the originally prescribed prescription drug; and</text> </level> <level label="2"> <text>charge the beneficiary no more than one copayment.</text> </level> </level> <level label="c"> <text>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.</text> </level> <level label="d"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1637" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>The toll–free telephone number shall be accessible from 8 a.m. until at least 8 p.m. Eastern Standard Time.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1638" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>All disclosures made under this part shall comply with the privacy standards set forth in State and federal law.</text> </section> <section article="gin" article_name="Insurance" number="15-1639" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <text>A pharmacy benefits manager shall establish appropriate policies and procedures to implement the requirements of this part. </text> </section> <section article="gin" article_name="Insurance" number="15-1642" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers"> <level label="a"> <text>It is a violation of this subtitle for a pharmacy benefits manager to:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>refuse to pay a claim for an arbitrary or capricious reason based on all available information;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>fail to act in good faith.</text> </level> </level> <level label="b"> <text>It is a violation of this subtitle for a pharmacy benefits manager, when committed at a frequency to indicate a general business practice, to:</text> <level label="1"> <text>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;</text> </level> <level label="2"> <text>fail to make a prompt, fair, and equitable good–faith attempt to settle claims for which liability has become reasonably clear;</text> </level> <level label="3"> <text>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</text> </level> <level label="4"> <text>refuse to pay a claim for an arbitrary or capricious reason based on all available information.</text> </level> </level> <level label="c"> <text>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:</text> <level label="1"> <text>cease and desist from the identified violation and further similar violations;</text> </level> <level label="2"> <text>take specific affirmative action to correct the violation;</text> </level> <level label="3"> <text>make restitution of money, property, or other assets to a person that has suffered financial injury because of the violation; or</text> </level> <level label="4"> <text>pay a fine in an amount determined by the Commissioner.</text> </level> </level> <level label="d"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="e"> <text>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.</text> </level> <level label="f"> <text>The Commissioner may adopt regulations:</text> <level label="1"> <text>to carry out this subtitle; and</text> </level> <level label="2"> <text>to establish a complaint process to address grievances and appeals brought in accordance with this subtitle.</text> </level> </level> <level label="g"> <text>This section does not limit any other regulatory authority of the Commissioner under this article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1701" title_number="15" title_name="Health Insurance" subtitle_number="17" subtitle_name="Regulation of Physician Rating Systems"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“Carrier” has the meaning stated in § 15–1301 of this title.</text> </level> <level label="c"> <text>“Enrollee” means an individual entitled to health care benefits from a carrier.</text> </level> <level label="d"> <text>“Physician rating system” means any program that:</text> <level label="1"> <text>measures, rates, or tiers the performance of physicians under contract with the carrier; and</text> </level> <level label="2"> <text>discloses the measures, rates, or tiers to enrollees or the public.</text> </level> </level> <level label="e"> <text>“Ratings examiner” means an independent entity that is approved by the Maryland Health Care Commission to review physician rating systems.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1702" title_number="15" title_name="Health Insurance" subtitle_number="17" subtitle_name="Regulation of Physician Rating Systems"> <level label="a"> <text>A carrier may not use a physician rating system unless the physician rating system is approved by a ratings examiner.</text> </level> <level label="b"> <text>A carrier shall contract with and pay for a ratings examiner to review any physician rating system of the carrier.</text> </level> <level label="c"> <text>A physician rating system of a carrier is deemed to meet the requirements of this section if the physician rating system:</text> <level label="1"> <text>is approved by a ratings examiner as of January 1, 2010; and</text> </level> <level label="2"> <text>notwithstanding any revisions to the physician rating system, maintains its approval by the ratings examiner.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1703" title_number="15" title_name="Health Insurance" subtitle_number="17" subtitle_name="Regulation of Physician Rating Systems"> <level label="a"> <text>A carrier that uses a physician rating system shall:</text> <level label="1"> <text>establish an appeals process for physicians to use to contest their rating; and</text> </level> <level label="2"> <text>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:</text> <level label="i"> <text>a notice of the proposed change;</text> </level> <level label="ii"> <text>an explanation of the data used to assess the physician and how the physician may access the data;</text> </level> <level label="iii"> <text>the methodology and measures used to assess the physician;</text> </level> <level label="iv"> <text>an explanation of the right to contest the rating of the physician through the appeals process of the carrier; and</text> </level> <level label="v"> <text>instructions on how to file a timely appeal with the carrier.</text> </level> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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:</text> <level label="1"> <text>where an enrollee can find the physician performance ratings of the carrier;</text> </level> <level label="2"> <text>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;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>any limitations of the data that the carrier uses to measure physician performance;</text> </level> <level label="5"> <text>the factors and criteria used in the carrier’s physician rating system, including quality of performance measures and cost efficiency measures; and</text> </level> <level label="6"> <text>how a physician may appeal a physician rating.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1704" title_number="15" title_name="Health Insurance" subtitle_number="17" subtitle_name="Regulation of Physician Rating Systems"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>correct the deficiency; or</text> </level> <level label="2"> <text>cease the use of the physician rating system.</text> </level> </level> <level label="c"> <text>A carrier using a physician rating system shall report annually to the Commissioner:</text> <level label="1"> <text>the number of appeals filed by physicians under this subtitle; and</text> </level> <level label="2"> <text>the outcome of the appeals.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1901" title_number="15" title_name="Health Insurance" subtitle_number="19" subtitle_name="Clinically Integrated Organizations"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“Carrier” means:</text> <level label="1"> <text>an insurer;</text> </level> <level label="2"> <text>a nonprofit health service plan; or</text> </level> <level label="3"> <text>a health maintenance organization.</text> </level> </level> <level label="c"> <text>“Clinically integrated organization” means:</text> <level label="1"> <text>a joint venture between a hospital and physicians that:</text> <level label="i"> <text>has received an advisory opinion from the Federal Trade Commission or its staff; and</text> </level> <level label="ii"> <text>has been established to:</text> <level label="1"> <text>evaluate and improve the practice patterns of the health care providers; and</text> </level> <level label="2"> <text>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</text> </level> </level> </level> <level label="2"> <text>a joint venture between a hospital and physicians that:</text> <level label="i"> <text>is accountable for total spending and quality; and</text> </level> <level label="ii"> <text>the Commissioner determines meets the criteria established by the federal Department of Health and Human Services for an accountable care organization.</text> </level> </level> </level> <level label="d"> <text>“Covered medical services” means the health care services that are included as benefits under a health benefit plan issued by a carrier.</text> </level> <level label="e"> <text>“Health benefit plan” has the meaning stated in § 15–1301 of this title.</text> </level> <level label="f"> <text>“Qualifying individual” means an individual covered under a health benefit plan issued by a carrier.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-1902" title_number="15" title_name="Health Insurance" subtitle_number="19" subtitle_name="Clinically Integrated Organizations"> <level label="a"> <text>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:</text> <level label="1"> <text>for services associated with the coordination of covered medical services to qualifying individuals; and</text> </level> <level label="2"> <text>a bonus, fee–based incentive, bundled fees, or other incentives to promote the efficient, medically appropriate delivery of covered medical services to qualifying individuals.</text> </level> </level> <level label="b"> <text>The Commissioner, in consultation with the Maryland Health Care Commission, may adopt regulations specifying the types of payments and incentives permissible under this section.</text> </level> <level label="c"> <level label="1"> <text>A carrier shall file a copy of a contract between the carrier and a clinically integrated organization with the Commissioner.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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:</text> <level label="i"> <text>confidential and privileged;</text> </level> <level label="ii"> <text>not subject to:</text> <level label="1"> <text>Title 4 of the General Provisions Article;</text> </level> <level label="2"> <text>subpoena; or</text> </level> <level label="3"> <text>discovery; and</text> </level> </level> <level label="iii"> <text>not admissible in evidence in any private action.</text> </level> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-1903" title_number="15" title_name="Health Insurance" subtitle_number="19" subtitle_name="Clinically Integrated Organizations"> <text>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:</text> <level label="1"> <text>the carrier has a written agreement with the clinically integrated organization specifying the type and proposed use of medical information to be shared;</text> </level> <level label="2"> <text>the medical information is used by the clinically integrated organization to:</text> <level label="i"> <text>promote the efficient, medically appropriate delivery of covered medical services to qualifying individuals;</text> </level> <level label="ii"> <text>coordinate care, including efforts to coordinate, plan, develop, monitor, share information related to, and otherwise initiate a treatment plan for a qualifying individual;</text> </level> <level label="iii"> <text>perform the functions of a medical review committee as described in § 1–401(c) of the Health Occupations Article; or</text> </level> <level label="iv"> <text>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</text> </level> </level> <level label="3"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2001" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“Independent pharmacy” means a pharmacy operating within the State that is under common ownership with not more than two other pharmacies.</text> </level> <level label="c"> <text>“Pharmacy benefits manager” has the meaning stated in § 15–1601 of this title.</text> </level> <level label="d"> <text>“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.</text> </level> <level label="e"> <level label="1"> <text>“Pharmacy services administrative organization” means an entity that provides a contracted pharmacy with contracting administrative services relating to prescription drug benefits.</text> </level> <level label="2"> <text>“Pharmacy services administrative organization” does not include a nonprofit health maintenance organization that:</text> <level label="i"> <text>operates as a group model;</text> </level> <level label="ii"> <text>provides services solely to a member or patient of the nonprofit health maintenance organization; and</text> </level> <level label="iii"> <text>furnishes services through the internal pharmacy operations of the nonprofit health maintenance organization.</text> </level> </level> </level> <level label="f"> <level label="1"> <text>“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.</text> </level> <level label="2"> <text>“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.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-2002" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>An applicant for registration shall:</text> <level label="1"> <text>file with the Commissioner an application on the form that the Commissioner provides; and</text> </level> <level label="2"> <text>pay to the Commissioner a registration fee set by the Commissioner.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-2003" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>A pharmacy services administrative organization may renew its registration for an additional 2–year term if the pharmacy services administrative organization:</text> <level label="1"> <text>otherwise is entitled to be registered;</text> </level> <level label="2"> <text>files with the Commissioner a renewal application on the form that the Commissioner requires; and</text> </level> <level label="3"> <text>pays to the Commissioner a renewal fee set by the Commissioner.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-2004" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <text>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.</text> </section> <section article="gin" article_name="Insurance" number="15-2005" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <text>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: </text> <level label="1"> <text>makes a material misstatement or misrepresentation in an application for registration;</text> </level> <level label="2"> <text>fraudulently or deceptively obtains or attempts to obtain a registration;</text> </level> <level label="3"> <text>in connection with the administration of pharmacy services administrative organization services, commits fraud or engages in illegal activities; or</text> </level> <level label="4"> <text>violates this subtitle or a regulation adopted under this subtitle.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2006" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <text>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:</text> <level label="1"> <text>in accordance with prudent standards of record keeping;</text> </level> <level label="2"> <text>for the duration of the agreement between the pharmacy services administrative organization and the independent pharmacy; and</text> </level> <level label="3"> <text>for 3 years after the pharmacy services administrative organization ceases to provide services as a pharmacy services administrative organization for the independent pharmacy.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2007" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>Whenever the Commissioner considers it advisable, the Commissioner may examine the affairs, transactions, accounts, and records of a registered pharmacy services administrative organization.</text> </level> <level label="b"> <text>The examination shall be conducted in accordance with § 2–207 of this article.</text> </level> <level label="c"> <text>The expense of the examination shall be paid in accordance with § 2–208 of this article.</text> </level> <level label="d"> <text>The reports of the examination and investigation shall be issued in accordance with § 2–209 of this article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2008" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <text>The Commissioner may adopt regulations to implement this subtitle. </text> </section> <section article="gin" article_name="Insurance" number="15-2009" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <text>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. </text> </section> <section article="gin" article_name="Insurance" number="15-2010" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>A pharmacy services administrative contract or an amendment to a pharmacy services administrative contract may not become effective unless:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>the Commissioner does not disapprove the filing within 60 days after the contract or amendment is filed.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>The Commissioner shall adopt regulations to:</text> <level label="1"> <text>establish the circumstances under which the Commissioner may disapprove a contract; and</text> </level> <level label="2"> <text>specify the types of amendments to a contract required to be filed under subsection (a) of this section.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-2011" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2012" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>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:</text> <level label="1"> <text>provides pharmacy services;</text> </level> <level label="2"> <text>provides prescription drug or device services; or</text> </level> <level label="3"> <text>manufactures, sells, or distributes prescription drugs, biologics, or medical devices.</text> </level> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2013" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>provides pharmacy services;</text> </level> <level label="2"> <text>provides prescription drug or device services; or</text> </level> <level label="3"> <text>manufactures, sells, or distributes prescription drugs, biologics, or medical devices.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2014" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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:</text> <level label="1"> <text>provides pharmacy services;</text> </level> <level label="2"> <text>provides prescription drug or device services; or</text> </level> <level label="3"> <text>manufactures, sells, or distributes prescription drugs, biologics, or medical devices.</text> </level> </level> <level label="c"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2015" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <text>A pharmacy services administrative contract shall:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2016" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>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.</text> </level> <level label="b"> <text>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.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2017" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>All disclosures made under this subtitle shall comply with the privacy standards established in federal and State law.</text> </level> <level label="b"> <text>A contract or amendment to a contract submitted to the Commissioner as required by this subtitle:</text> <level label="1"> <text>is considered to be confidential and proprietary information; and</text> </level> <level label="2"> <text>is not subject to disclosure under the Public Information Act.</text> </level> </level> </section> <section article="gin" article_name="Insurance" number="15-2018" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <text>A pharmacy services administrative organization shall establish appropriate policies and procedures to implement the requirements of this subtitle.</text> </section> <section article="gin" article_name="Insurance" number="15-2019" title_number="15" title_name="Health Insurance" subtitle_number="20" subtitle_name="Pharmacy Services Administrative Organizations"> <level label="a"> <text>A pharmacy services administrative organization may not:</text> <level label="1"> <text>misrepresent pertinent facts or policy provisions that relate to an issue in a dispute or an appeal of a decision regarding a dispute;</text> </level> <level label="2"> <text>refuse to pay or reimburse an independent pharmacy for an arbitrary or capricious reason based on all available information;</text> </level> <level label="3"> <text>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;</text> </level> <level label="4"> <text>fail to act in good faith; or</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="b"> <text>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:</text> <level label="1"> <text>cease and desist from the identified violation and further similar violations;</text> </level> <level label="2"> <text>take specific affirmative action to correct the violation;</text> </level> <level label="3"> <text>make restitution of money, property, and other assets to a person that has suffered financial injury because of the violation; or</text> </level> <level label="4"> <text>pay a fine in the amount determined by the Commissioner.</text> </level> </level> <level label="c"> <level label="1"> <text>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.</text> </level> <level label="2"> <text>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.</text> </level> <level label="3"> <text>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.</text> </level> <level label="4"> <text>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.</text> </level> <level label="5"> <text>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.</text> </level> </level> <level label="d"> <text>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.</text> </level> <level label="e"> <text>The Commissioner may adopt regulations:</text> <level label="1"> <text>to carry out this section; and</text> </level> <level label="2"> <text>to establish a complaint process to address grievances and appeals brought in accordance with this section.</text> </level> </level> <level label="f"> <text>This section does not limit any other regulatory authority of the Commissioner under this article.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2101" title_number="15" title_name="Health Insurance" subtitle_number="21" subtitle_name="Capitated Payments"> <level label="a"> <text>In this subtitle the following words have the meanings indicated.</text> </level> <level label="b"> <text>“Administrator” means a carrier administering a self–funded group health plan.</text> </level> <level label="c"> <text>“Carrier” has the meaning stated in § 15–113 of this title.</text> </level> <level label="d"> <text>“Health benefit plan” has the meaning stated in § 2–112.2 of this article.</text> </level> <level label="e"> <text>“Health care practitioner” has the meaning stated in § 15–113 of this title.</text> </level> <level label="f"> <text>“Member” has the meaning stated in § 15–10A–01 of this title.</text> </level> <level label="g"> <text>“Network” has the meaning stated in § 15–112 of this title.</text> </level> <level label="h"> <text>“Participant” means an employee or an employee’s dependent who participates in a self–funded group health insurance plan.</text> </level> <level label="i"> <text>“Set of health care practitioners” has the meaning stated in § 15–113 of this title.</text> </level> </section> <section article="gin" article_name="Insurance" number="15-2102" title_number="15" title_name="Health Insurance" subtitle_number="21" subtitle_name="Capitated Payments"> <level label="a"> <text>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:</text> <level label="1"> <text>calculated as a fixed amount per member or participant assigned or attributed to the health care practitioner or set of health care practitioners;</text> </level> <level label="2"> <text>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</text> </level> <level label="3"> <text>paid periodically regardless of utilization of the services by the members or participants.</text> </level> </level> <level label="b"> <text>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.</text> </level> <level label="c"> <text>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:</text> <level label="1"> <text>the health care practitioner or set of health care practitioners participates in the administrator’s network and accepts capitated payments;</text> </level> <level label="2"> <text>the self–funded group health plan retains the obligation to provide access to covered health care benefits to participants; and</text> </level> <level label="3"> <text>the contract does not include other reimbursement arrangements that are considered acts of an insurance business under § 4–205(c) of this article.</text> </level> </level> <level label="d"> <text>Notwithstanding subsections (b) and (c) of this section, nothing in this section may be construed to:</text> <level label="1"> <text>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</text> </level> <level label="2"> <text>supersede the Health Services Cost Review Commission’s jurisdiction or authority over rate review and approval for hospital services.</text> </level> </level> </section>