Title 15. Health Insurance — Subtitle 1. General Provisions

provide additional benefits in case of dismemberment, loss of sight, or death by accident or accidental means;

provide additional benefits for long-term home health care and long-term care in a nursing home or other related institution; or

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.

written in simplified language; and

approved by the Commissioner as complying with the simplified language standards adopted under subsection (c) of this section.

on or after January 2, 1992; or

on or after July 2, 1997, if the policy or certificate was approved by the Commissioner on or before January 1, 1992.

In this section the following words have the meanings indicated.

“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.

“Specified disease policy” has the meaning stated in § 15-109 of this subtitle.

other health insurance policies, including commercial individual, group, and blanket policies and policies of nonprofit health service plans;

subscriber contracts that are issued by health maintenance organizations; and

other established programs under which the insured may make a claim.

In this section the following words have the meanings indicated.

“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.

“Breast implant-related condition” means a condition that the federal Food and Drug Administration recognizes as possibly linked to breast implants.

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

health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.

coverage for breast implant removals and breast implant-related conditions; and

preexisting condition provisions in policies for individuals with breast implants.

On request, the Commissioner shall make available to consumers and licensed physicians the information collected under subsection (c) of this section.

When providing the information, the Commissioner may include a statement that the Commissioner does not guarantee the accuracy of the information.

The Commissioner may set a fee to cover the cost of providing the information under paragraph (1) of this subsection.

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:

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:

Rented home medical equipment and services may be purchased with the consent of the provider and insurer if:

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.

exclusion of coverage for classes of drugs as specified by the contract;

changes in prior or preauthorization procedures; or

selection of new prescription claims processors.

In this section the following words have the meanings indicated.

“Loss ratio” means the ratio of losses incurred to premiums earned on policies that are issued, delivered, or renewed in the State.

“Specified disease policy” means a health insurance policy that provides:

In this section the following words have the meanings indicated.

“Health care practitioner” has the meaning stated in § 1–301 of the Health Occupations Article.

“Health care service” has the meaning stated in § 1–301 of the Health Occupations Article.

“Prohibited referral” means a referral prohibited by § 1–302 of the Health Occupations Article.

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.

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.

In this section the following words have the meanings indicated.

“Accredited hospital” has the meaning stated in § 19–301 of the Health – General Article.

“Ambulatory surgical facility” has the meaning stated in § 19–3B–01 of the Health – General Article.

“Behavioral health care services” has the meaning stated in § 15–127 of this subtitle.

“Credentialing intermediary” means a person to whom a carrier has delegated credentialing or recredentialing authority and responsibility.

“Enrollee” means a person entitled to health care benefits from a carrier.

“Group model health maintenance organization” has the meaning stated in § 19–713.6(a) of the Health – General Article.

“Health benefit plan”:

“Hospital” has the meaning stated in § 19–301 of the Health – General Article.

“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.

“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.

“Participating provider” means a provider on a carrier’s provider panel.

“Provider” means a health care practitioner or group of health care practitioners licensed, certified, or otherwise authorized by law to provide health care services.

“Provider directory” means a list of a carrier’s participating providers and participating health care facilities.

Subject to paragraph (3) of this subsection, a carrier that uses a provider panel shall:

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.

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:

The notice required under paragraph (1)(ii)2 of this subsection shall include:

This subsection applies to a carrier that:

An access plan filed under this subsection shall include a description of:

Each carrier shall monitor, on an ongoing basis, the clinical capacity of its participating providers to provide covered services to its enrollees.

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.

In adopting the regulations, the Commissioner may take into consideration:

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.

The regulations shall:

In establishing the standards for dental services, the Commissioner may consider the appropriateness of quantitative and nonquantitative criteria.

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;

shall make publicly available its application; and

shall make efforts to increase the opportunity for a broad range of minority providers to participate on the carrier’s provider panel.

A provider that seeks to participate on a provider panel of a carrier shall submit an application to the carrier.

A carrier may charge a reasonable fee for an application submitted to the carrier under this section.

sex, sexual orientation, gender identity, race, age, religion, national origin, or a protected category under the federal Americans with Disabilities Act;

the type or number of appeals that the provider files under Subtitle 10B of this title;

the number of grievances or complaints that the provider files on behalf of a patient under Subtitle 10A of this title; or

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.

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.

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.

A violation of this subsection does not create a new cause of action.

Subject to the provisions of this subsection, a carrier may not require a provider participating on its provider panel to be recredentialed based on:

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.

The notice required under paragraph (2) of this subsection shall include:

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.

Within 30 business days after receipt of the notice required under paragraph (2) of this subsection, a carrier:

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.

advocating the interests of a patient through the carrier’s internal review system established under subsection (l) of this section;

filing an appeal under Subtitle 10B of this title; or

filing a grievance or complaint on behalf of a patient under Subtitle 10A of this title.

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:

A carrier shall reimburse a provider that furnishes health care services under this subsection in accordance with the provider’s agreement with the carrier.

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.

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.

The carrier’s provider directory on the Internet shall be available:

The provider directory shall include:

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.

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.

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.

A carrier shall:

A carrier shall demonstrate the accuracy of the information provided under paragraph (3) of this subsection on request of the Commissioner.

A carrier shall include in a provider directory that is in printed form a statement notifying a reader that:

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:

indicate clearly the office in the Administration that is responsible for receiving and responding to complaints from enrollees about carriers; and

include the telephone number of the office and the procedure for filing a complaint.

shall adopt regulations that relate to the procedures that carriers must use to process applications for participation on a provider panel; and

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.

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;

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

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.

Notification is presumed to have been received by a carrier:

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:

A nonparticipating provider shall notify an enrollee:

is a hospital or academic medical center;

is a participating provider on the carrier’s provider panel; and

acts as a credentialing intermediary for that carrier for health care practitioners that:

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:

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.

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.

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.

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.

A group practice shall disclose in writing to an enrollee at the time services are provided that:

In this subsection, “health system” means:

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:

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.

In this section the following words have the meanings indicated.

“Credentialing intermediary” means a person to whom a carrier has delegated credentialing or recredentialing authority and responsibility.

“Health care provider” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.

“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.

“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.

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.

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.

is a participating provider on the carrier’s provider panel; and

acts as a credentialing intermediary for that carrier for health care practitioners that:

The Commissioner may adopt regulations to implement the provisions of this section.

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:

In this section the following words have the meanings indicated.

“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.

“Carrier” means:

“Enrollee” means a person entitled to health care benefits from a carrier.

“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.

“HMO provider panel” means a provider panel for one or more health maintenance organizations.

“Managed care organization” has the meaning stated in § 15–101 of the Health – General Article.

“Non–HMO provider panel” means a provider panel for one or more nonprofit health service plans or insurers.

“Provider” has the meaning stated in § 19–701 of the Health – General Article.

“Provider contract” means a contract:

“Provider panel” means the providers that contract either directly or through a subcontracting entity with a carrier to provide health care services to enrollees.

A provider contract may not contain a provision that requires a provider:

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.

This subsection does not apply to a provider contract for a dental provider panel.

Each provider contract shall disclose the carriers comprising each provider panel.

This subsection does not apply to a provider contract for a dental provider panel.

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.

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.

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.

notify the carrier at least 90 days before the date of termination; and

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.

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.

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.

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.

A carrier may not include in a vision provider contract a provision that requires a vision provider:

In this section the following words have the meanings indicated.

“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.

the system is available to providers nationally;

the system is available to providers at no charge;

the system allows providers to:

the nonprofit alliance has a well–established mechanism for outreach to providers.

from:

In this section the following words have the meanings indicated.

“Carrier” means:

“Eligible provider” means:

“Health care practitioner” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.

“Set of health care practitioners” means:

“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.

This section does not prohibit a carrier from:

A bonus or other incentive–based compensation program or two–sided incentive arrangement authorized under this section:

A bonus or other incentive–based compensation or two–sided incentive arrangement authorized under this section:

Acceptance of a bonus or other incentive–based compensation or two–sided incentive arrangement under this subsection shall be voluntary.

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.

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.

A carrier may not require as a condition of participation in the carrier’s provider network:

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.

A carrier shall provide a health care practitioner, a set of health care practitioners, or an eligible provider with a copy of:

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:

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.

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.

The Administration may adopt regulations to carry out the provisions of this subsection.

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.

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.

Acceptance of a capitated payment shall be voluntary.

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:

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.

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:

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.

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.

Nothing in this subsection may be construed to:

In this section the following words have the meanings indicated.

“Carrier” means:

“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.

“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.

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.

If a carrier’s dental provider panel is the sole delivery system offered to employees by an employer, the carrier:

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.

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.

In this section, “carrier” means:

“Carrier” includes an entity that arranges a provider panel for a carrier.

In this section the following words have the meanings indicated.

“Carrier” means:

“Health care provider” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.

communications that relate to treatment alternatives;

communications that are necessary or appropriate to maintain the provider-patient relationship while the patient is under the health care provider’s care;

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

opinions and the basis of an opinion about public policy issues.

In this section the following words have the meanings indicated.

“Health care service” means a health or medical care procedure or service rendered by a provider that:

“Provider” means a physician, hospital, or other person that is licensed or otherwise authorized to provide health care services.

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

health maintenance organizations that provide coverage for health care services to individuals or groups under contracts that are issued or delivered in the State.

modify the uniform consultation referral form; or

submit additional consultation referral forms.

shall be properly completed by the health care provider that refers the insured for consultation services; and

may be transmitted electronically.

In this section the following words have the meanings indicated.

“Carrier” means:

“Contract” means any written agreement between a provider and a carrier for the provider to render health care services to enrollees of the carrier.

“Enrollee” means any person or subscriber entitled to health care benefits from a carrier.

“Health care services” means a health or medical care procedure or service rendered by a provider that:

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.

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.

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.

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”):

an insurer;

a nonprofit health service plan;

a health maintenance organization;

a dental plan organization; or

any other person that provides health benefit plans subject to regulation by the State.

In this section the following words have the meanings indicated.

“Advance directive” has the meaning stated in § 5–601 of the Health – General Article.

to all members or enrollees in initial enrollment materials distributed after initial purchase and upon renewal and in the carrier’s member publications;

if the carrier maintains a website, on the carrier’s website; and

at the request of a member.

assist a member or enrollee in drafting an electronic advance care planning document;

store electronic advance care planning documents; or

access advance care planning documents.

In this section the following words have the meanings indicated.

“Carrier” means:

“Contract” means any written agreement between a provider and a carrier for the provider to render health care services to enrollees of the carrier.

“Diagnostic services” means any medical or surgical service or procedure that allows a provider to identify or diagnose a human disease or disorder.

“Enrollee” means any person or subscriber entitled to health care benefits from a carrier.

“Health care services” means a health or medical care procedure or service rendered by a provider that:

“Therapeutic services” means any medical or surgical service or procedure that a provider can use to treat a human disease or disorder.

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

affect the right of an enrollee to appeal any adverse decision by a carrier through the carrier’s appeal process.

Each carrier shall disclose to providers and enrollees the carrier’s definition of “experimental medical care”.

The carrier shall disclose the definition in:

a comprehensive review of medical literature and data evaluation; and

input from physicians and other recognized experts:

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.

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.

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.

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.

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.

In this section the following words have the meanings indicated.

“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.

“Health care provider” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.

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.

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.

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.

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.

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.

placing the patient’s health in serious jeopardy;

serious impairment to bodily functions; or

serious dysfunction of any bodily organ or part.

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

health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.

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.

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.

In this section the following words have the meanings indicated.

“Carrier” means:

“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.

“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.

“Managed behavioral health care organization” means a company, organization, private review agent, or subsidiary that:

“Provider” means a person licensed, certified, or otherwise authorized under the Health Occupations Article or the Health – General Article to provide health care services.

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:

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.

A carrier that owns or contracts with a managed behavioral health care organization shall:

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:

The Commissioner shall develop a form to implement the requirements of this subsection.

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.

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:

In this section the following words have the meanings indicated.

“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.

“Carrier” means:

“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.

“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.

“Medical stop–loss insurer” means a carrier that is authorized to sell, issue, and deliver policies of medical stop–loss insurance in the State.

“Small employer” has the meaning stated in § 31–101 of this article.

“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.

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:

This subsection does not apply to:

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:

guarantee rates for at least 12 months, without adjustment, unless there is a change in:

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

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:

imposing any requirement or duty on any person other than a carrier; or

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.

This section applies to:

This section does not apply to:

indicates which State agency regulates, in whole or in part, the policy or contract offered by the entity by: