This title does not apply to: a policy of liability or workers’ compensation and employer’s liability insurance; a group or blanket policy, except as otherwise provided in this title; reinsurance; or 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: 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.

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.

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: written in simplified language; and approved by the Commissioner as complying with the simplified language standards adopted under subsection (c) of this section. Subsection (a) of this section applies: 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. 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.

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. 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: 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. 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. 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.

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. This section applies to: 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. An entity subject to this section shall provide information to the Commissioner about the entity’s: 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. A licensed physician may make available to a patient the information obtained from the Commissioner under subsection (d) of this section. 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.

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: shall pay the home medical equipment provider directly if the insured has executed an assignment of benefits; and 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. 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: shall pay the home medical equipment provider directly if the contract, policy, or certificate of insurance provides for direct payment; 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 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. Authorization may not be terminated until both the provider and beneficiary of the home medical equipment have been notified that authorization is terminated. Rented home medical equipment and services may be purchased with the consent of the provider and insurer if: 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 there is no material change in the medical condition of the insured, as certified by the attending physician. 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.

This section applies to insurers and nonprofit health service plans that issue or deliver individual, group, or blanket health insurance policies in the State. 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: 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. 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.

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.

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: benefits only for a disease or diseases specified in the policy or for a treatment unique to a specified disease or diseases; or additional benefits for a disease or diseases specified in the policy or for treatment unique to a specified disease or diseases. 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. 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.

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. This section applies to insurers and nonprofit health service plans that issue or deliver individual or group health insurance policies in the State. 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. 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. 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. 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 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.

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. 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.

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. “Carrier” means: 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. “Carrier” includes an entity that arranges a provider panel for a carrier. “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”: for a group or blanket plan in the large group market, has the meaning stated in § 15–1401 of this title; for a group in the small group market, has the meaning stated in § 31–101 of this article; and for an individual plan, has the meaning stated in § 15–1301 of this title. “Health care facility” means a health care setting or institution providing physical, mental, or substance use disorder health care services. “Health care facility” includes: a hospital; an ambulatory surgical or treatment center; a skilled nursing facility; a residential treatment center; an urgent care center; a diagnostic, laboratory, or imaging center; a rehabilitation facility; and any other therapeutic health care setting. “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. “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. “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. Subject to paragraph (3) of this subsection, a carrier that uses a provider panel shall: 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 establish procedures to: review applications for participation on the carrier’s provider panel in accordance with this section; notify an enrollee of: 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 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; notify primary care providers on the carrier’s provider panel of the termination of a specialty referral services provider; 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 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. 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: ensure that all enrollees, including adults and children, have access to providers and covered services without unreasonable travel or delay; include standards that ensure access to providers, including essential community providers, that serve predominantly low–income and medically underserved individuals; or 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 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. The notice required under paragraph (1)(ii)2 of this subsection shall include: 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; 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 the telephone number and e–mail address for the office in the Administration that is responsible for receiving and responding to complaints. This subsection applies to a carrier that: is an insurer, a nonprofit health service plan, or a health maintenance organization; and uses a provider panel for a health benefit plan offered by the carrier. 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. 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: subject to subparagraph (iv) of this paragraph, notify the Commissioner of the impending termination at least 60 days before the anticipated date of termination; 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 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. The Commissioner may order corrective action if, after review, the access plan is determined not to meet the requirements of this subsection. The notice required under subparagraph (ii)1 of this paragraph shall be provided if: the provider or health care facility provides advance notice to the carrier of its intention to terminate participation in the carrier’s provider panel; 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; 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 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. 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: the provider specialty types affected by the material change; and unless the network as a whole experienced a 10% reduction, the geographic areas where enrollees were affected by the material change. 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. 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. 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. An access plan filed under this subsection shall include a description of: 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; 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; 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; the carrier’s efforts to address the needs of both adult and child enrollees, including adults and children with: limited English proficiency or illiteracy; diverse cultural or ethnic backgrounds; physical or mental disabilities; and serious, chronic, or complex health conditions; the carrier’s efforts to include providers, including essential community providers, in its network who serve predominantly low–income, medically underserved individuals; or 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; 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 the carrier’s methods for assessing the health care needs of enrollees and enrollee satisfaction with health care services provided to them. 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: geographic accessibility of primary care and specialty providers, including mental health and substance use disorder providers; waiting times for an appointment with participating primary care and specialty providers, including mental health and substance use disorder providers; primary care provider–to–enrollee ratios; provider–to–enrollee ratios, by specialty; geographic variation and population dispersion; hours of operation; the ability of the network to meet the needs of enrollees, which may include: low–income individuals; adults and children with: serious, chronic, or complex health conditions; or physical or mental disabilities; and individuals with limited English proficiency or illiteracy; other health care service delivery system options, including telemedicine, telehealth, mobile clinics, and centers of excellence; the volume of technological and specialty care services available to serve the needs of enrollees requiring technologically advanced or specialty care services; any standards adopted by the federal Centers for Medicare and Medicaid Services or used by the Federally Facilitated Marketplace; and any standards adopted by another state. 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: ensure that all enrollees, including adults and children, have access to providers and covered services without unreasonable delay and travel; ensure access to providers, including essential community providers, that serve predominantly low–income, medically underserved individuals; and 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. In establishing the standards for dental services, the Commissioner may consider the appropriateness of quantitative and nonquantitative criteria. A carrier that uses a provider panel: 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. 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. 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: a licensed master social worker, as defined in § 19–101 of the Health Occupations Article; 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 a registered psychology associate, as defined in § 18–101 of the Health Occupations Article. 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. 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: the carrier’s intent to continue to process the provider’s application to obtain necessary credentialing information; or the carrier’s rejection of the provider for participation on the carrier’s provider panel. 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. 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: accept or reject the provider for participation on the carrier’s provider panel; and send written notice of the acceptance or rejection to the provider at the address listed in the application. 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: accept or reject the provider for participation on the carrier’s provider panel; and send written notice of the acceptance or rejection to the provider at the address listed in the application. 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. 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. 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. 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. 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. 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. The carrier shall indicate to the provider what information is needed to make the application complete. The provider may return the completed application to the carrier. After the carrier receives the completed application, the carrier is subject to the time periods established in paragraph (3) of this subsection. A carrier may charge a reasonable fee for an application submitted to the carrier under this section. A carrier may not deny an application for participation or terminate participation on its provider panel on the basis of: 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 change in the federal tax identification number of the provider; a change in the federal tax identification number of a provider’s employer; or a change in the employer of a provider, if the new employer is: a participating provider on the carrier’s provider panel; or the employer of providers that participate on the carrier’s provider panel. 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: 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; the effective date of the change in the federal tax identification number of the provider or the provider’s employer; 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 the following information about a new employer of the provider: the employer’s name; the name of the employer’s contact person for carrier questions about the provider; and the address, telephone number, facsimile transmission number, and electronic mail address of the contact person for the employer. 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: shall acknowledge receipt of the notice to the provider or the provider’s employer; and 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: the provider or the provider’s employer; or the representative of the provider or the provider’s employer designated in writing to the 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. A carrier may not terminate participation on its provider panel or otherwise penalize a provider for: 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. 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. 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: who was receiving health care services from the provider before the notice of termination; and 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. 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: through a clear link or tab; and in a searchable format. The provider directory shall include: for each provider on the carrier’s provider panel: the name of the provider; the specialty areas of the provider; whether the provider currently is accepting new patients; for each office of the provider where the provider participates on the provider panel: its location, including its address; and contact information for the provider; 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 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; for each health care facility in the carrier’s network: the health care facility’s name; the health care facility’s address; the types of services provided by the health care facility; and contact information for the health care facility; and 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. 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. Information provided in printed form under subsection (n) of this section shall be accurate on the date of publication. A carrier shall update the information provided in printed form at least once a year. Information provided on the Internet under subsection (n) of this section shall be accurate on the date of initial posting and any update. 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. A carrier shall: periodically review at least a reasonable sample size of its provider directory for accuracy; and retain documentation of the review and make the review available to the Commissioner on request; or 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. 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: the information contained in the provider directory is accurate as of the date of publication; and to obtain the most current information, the individual should consult the provider directory on the Internet or contact the carrier directly. 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: 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: through the multi–carrier common online provider directory information system designated under § 15–112.3 of this subtitle; or directly with the carrier; 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; 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; the carrier includes in its network directory the last date that a provider updated the provider’s information; the carrier has implemented any other process or procedure to: encourage providers to update their network directory information; or increase the accuracy of its network directory; and 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. A policy, certificate, or other evidence of coverage shall: 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. The Commissioner: 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. A carrier may not include in a contract with a provider, ambulatory surgical facility, or hospital a term or condition that: 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. 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. 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. Notification is presumed to have been received by a carrier: 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 on the date recorded by the courier, if the notification was delivered by courier. 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: 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 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. A nonparticipating provider shall notify an enrollee: that the provider does not participate on the provider panel of the enrollee’s carrier; and of the anticipated total charges for the health care services. The provisions of subsection (g)(3)(iii) of this section do not apply to a carrier that uses a credentialing intermediary that: 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: participate on the carrier’s provider panel; and have privileges at the hospital or academic medical center. 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: the provider is employed by or a member of the group practice; 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; the provider has a valid license issued by a health occupations board to practice in the State; and the provider: is currently credentialed by an accredited hospital in the State; or has professional liability insurance. 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: the treating provider is not a participating provider; the treating provider has applied to become a participating provider; the carrier has not completed its assessment of the qualifications of the treating provider to provide services as a participating provider; and any covered services received must be reimbursed by the carrier at the participating provider rate. 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. In this subsection, “health system” means: a hospital and any entity affiliated with the hospital through ownership, governance, membership, or other means; or a parent corporation of one or more hospitals and any entity affiliated with the parent corporation through ownership, governance, membership, or other 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: at least 90 days before the proposed date of the termination of the contract; or in the case of nonrenewal, at least 90 days before the end of the contract period. 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: at least 90 days after the date of termination; or in the case of a nonrenewal, at least 90 days after the end of the contract period. 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: the date of termination; or in the case of a nonrenewal, the end date of the contract period. This paragraph does not apply if the carrier and health system: agree, in writing, to the termination or nonrenewal of the contract; and provide the notices required under paragraph (2) of this subsection. 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. “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: an insurer; a nonprofit health service plan; a health maintenance organization; or a dental plan organization. “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: between a provider and a carrier, an affiliate of a carrier, or an entity that contracts with a provider to serve a carrier; and under which the provider agrees to provide health care services to enrollees. “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: as a condition of participating in a non–HMO provider panel, to participate in an HMO provider panel; or as a condition of participating in a fee–for–service dental provider panel, to participate in a capitated dental provider panel. 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. If a provider elects to terminate participation on a provider panel, the provider shall: 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. 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. 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: to provide health care services that are not covered services at a fee set by the carrier; or to provide discounts on materials that are not covered benefits. 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. 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.

In this section the following words have the meanings indicated. “Carrier” has the meaning stated in § 15–112 of this subtitle. “Carrier” does not include a managed care organization, as defined in Title 15, Subtitle 1 of the Health – General Article. “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 Commissioner may designate a multi–carrier common online provider directory information system developed by a nonprofit alliance of health plans and trade associations if: the system is available to providers nationally; the system is available to providers at no charge; the system allows providers to: attest online to the accuracy of their information; and correct any inaccurate information; and attest to the correction; and the nonprofit alliance has a well–established mechanism for outreach to providers. A carrier shall accept new and updated provider directory information for a provider submitted: through the multi–carrier common online provider directory information system; or directly to the carrier; and from: the provider; a hospital or academic medical center that: is a participating provider on the carrier’s provider panel; and acts as a credentialing intermediary for the carrier for providers that: participate on the carrier’s provider panel; and have privileges at the hospital or academic medical center; or any other person that performs credentialing functions on behalf of a provider.

In this section the following words have the meanings indicated. “Carrier” means: 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. “Eligible provider” means: a licensed physician, as defined in § 14–101 of the Health Occupations Article, who voluntarily participates in a two–sided incentive arrangement; or a set of health care practitioners that voluntarily participate in a two–sided incentive arrangement. “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: a group practice; a clinically integrated organization established in accordance with Subtitle 19 of this title; an accountable care organization established in accordance with 42 U.S.C. § 1395jjj and any applicable federal regulations; or 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. “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. 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. This section does not prohibit a carrier from: providing bonuses or other incentive–based compensation to a health care practitioner or a set of health care practitioners; or entering into a two–sided incentive arrangement with an eligible provider. A bonus or other incentive–based compensation program or two–sided incentive arrangement authorized under this section: may not create a disincentive to the provision of medically appropriate or medically necessary health care services; and if the carrier is a health maintenance organization, shall comply with the provisions of § 19–705.1 of the Health – General Article. A bonus or other incentive–based compensation or two–sided incentive arrangement authorized under this section: if applicable, shall promote health equity, improvement of health care outcomes, and the provision of preventive health care services; or 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: the performance measures, including the source of the measures; the method and the time period for calculating whether the performance measures have been satisfied; 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 if applicable, the risk–adjustment method used. 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 or set of health care practitioners to participate in the carrier’s bonus or other incentive–based compensation program; or an eligible provider to participate in the carrier’s two–sided incentive arrangement program. 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: a schedule of all applicable fees or the 50 most common services billed by a health care practitioner in that specialty, whichever is less; 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; the information about the practitioner and the methodology that the carrier uses to determine whether to: increase or reduce the practitioner’s level of reimbursement; provide a bonus or other incentive–based compensation to the practitioner; and recoup compensation from an eligible provider under a two–sided incentive arrangement; and a summary of the terms of a two–sided incentive arrangement program. 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: in writing before a contract execution; in writing or electronically 30 days before a change; and in writing or electronically on request of the health care practitioner, set of health care practitioners, or eligible provider. 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: establish a target budget for: the total cost of care of a population of patients adjusted for risk and population size; or the cost of an episode of care; 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; 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; provide an opportunity for gains by an eligible provider that is greater than the opportunity for recoupment by the carrier; following good faith negotiations, provide an opportunity for an audit by an independent third party and an independent third–party dispute resolution process; require the carrier and the eligible provider to negotiate in good faith adjustments to the target budget when: certain circumstances beyond the control of the carrier or the eligible provider arise, including changes in hospital rates; and material changes occur in health care economics, health care delivery, or regulations that impact the arrangement; and 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. 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: 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 any copayment, coinsurance, or deductible that is included in the total cost of care of a patient in the population or episode of care. 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: 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 supersede the Health Services Cost Review Commission’s jurisdiction or authority over rate review and approval for hospital services.

In this section, “carrier” means: 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. “Carrier” includes an entity that arranges a provider panel for a carrier. 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.

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. 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.

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: provides testing, diagnosis, or treatment of human disease or dysfunction; or dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of human disease or dysfunction. “Provider” means a physician, hospital, or other person that is licensed or otherwise authorized to provide health care services. This section applies to: 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. 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. 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.

This section applies to insurers and nonprofit health service plans that issue or deliver individual, group, or blanket health insurance policies in the State. 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. An entity subject to this section may not impose as a condition of coverage a requirement to: modify the uniform consultation referral form; or submit additional consultation referral forms. The uniform consultation referral form: shall be properly completed by the health care provider that refers the insured for consultation services; and may be transmitted electronically.

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. 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. 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.

In this section the following words have the meanings indicated. “Carrier” means: an insurer; a nonprofit health service plan; a health maintenance organization; a dental plan organization; any person or entity acting as a third party administrator; or 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. “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: provides testing, diagnosis, or treatment of a human disease or dysfunction; or dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction. “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. “Provider” includes: a health care facility; a pharmacy; a professional services corporation; a partnership; a limited liability company; a professional office; and any other entity licensed or authorized by law to provide or deliver professional health care services through or on behalf of a provider. 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. 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”): 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 the proportion of every $100 in premium dollars that the carrier uses to pay for plan administration.

In this section, “carrier” means: 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. 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. 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.

In this section the following words have the meanings indicated. “Advance directive” has the meaning stated in § 5–601 of the Health – General Article. “Carrier” means: an insurer; a nonprofit health service plan; a health maintenance organization; and any other person that provides health benefit plans subject to regulation by the State. “Carrier” does not include a managed care organization. A carrier shall provide the advance directive information sheet developed under § 5–615 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. 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. This section may not be construed to require a carrier to: 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: an insurer; a nonprofit health service plan; a health maintenance organization; a dental plan organization; any person or entity acting as a third party administrator; or 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. “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: provides testing, diagnosis, or treatment of a human disease or dysfunction; or dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction. “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. “Provider” includes: a health care facility; a pharmacy; a professional services corporation; a partnership; a limited liability company; a professional office; and any other entity licensed or authorized by law to provide or deliver professional health care services through or on behalf of a provider. “Therapeutic services” means any medical or surgical service or procedure that a provider can use to treat a human disease or disorder. 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. The section does not: 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: contracts offered to providers that may render direct health care services to the enrollees of the carrier; and marketing materials and enrollment materials of the carrier that are provided to current enrollees and prospective enrollees, as appropriate. 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. The process established or subscribed to or contracted for by a carrier under subsection (e) of this section shall include: a comprehensive review of medical literature and data evaluation; and input from physicians and other recognized experts: who are not employees of the carrier; and who: are currently treating patients for the disease or condition being evaluated; are board certified in the pertinent specialty or subspecialty area of the disease or condition being evaluated; are generally recognized by their peers to be authoritative resources in the clinical area being evaluated as evidenced by: faculty appointments; authorship of a significant body of peer–reviewed clinical literature in the pertinent specialty or subspecialty area; or 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 have a demonstrated history of substantial experience and practical knowledge in the specialty or subspecialty area in question. 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. 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. 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. 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. 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. 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. The Commissioner may adopt regulations to carry out this section.

In this section, “group health insurance” has the meaning stated in § 15–301 of this title. This section applies to insurers and nonprofit health service plans that issue or deliver group health insurance policies in the State. 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.

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: placing the patient’s health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. This section applies to: 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. 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. 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.

In this section the following words have the meanings indicated. “Behavioral health care administrative expenses” means any expenses that are for administrative functions including: billing and collection expenses; accounting and financial reporting expenses; quality assurance and utilization management program or activity expenses; promotion and marketing expenses; taxes, fees, and assessments; legal expenses; salary expenses for employees that are not related to the delivery of behavioral health care services to patients; computer expenses; provider credentialing; collection and administrative review of treatment plans; auditing the financial report submitted to the Commissioner under this section; debt payment and debt service; and other general and administrative expenses. “Behavioral health care administrative expenses” does not include expenses incurred for behavioral health care services. “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. “Behavioral health care services” includes any quality assurance or utilization management activities or treatment plan reviews that are clinical in nature. “Behavioral health care services” does not include administrative functions. “Carrier” means: a health insurer; a nonprofit health service plan; a health maintenance organization; a preferred provider organization; a third party administrator; or 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. “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: contracts with a carrier to provide, undertake to arrange, or administer behavioral health care services to members; or otherwise makes behavioral health care services available to members through contracts with health care providers. “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. “Member” includes a subscriber. “Provider” means a person licensed, certified, or otherwise authorized under the Health Occupations Article or the Health – General Article to provide health care services. 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. 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 specific behavioral health care services covered and the specific exclusions under the member’s contract; the member’s responsibilities for obtaining behavioral health care services; the reimbursement methodology that the carrier and managed behavioral health care organization use to reimburse providers for behavioral health care services; and 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. 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: 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 provide the same information on behavioral health care providers that is required for other providers under § 15–112(n) of this subtitle. 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. The report required under subparagraph (i) of this paragraph shall be made publicly available by the carrier. 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 carrier’s direct payments for the preceding calendar year; the information required to be collected by a carrier under subsection (c)(4) of this section; and 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. 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: a reasonable preparation fee not to exceed $15 for each form requested; and the actual cost for any postage and handling required to provide copies of the requested forms. The Commissioner may adopt regulations to carry out the provisions of this section.

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: an insurer; or a nonprofit health service plan. “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. 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. 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. 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: a specific attachment point of less than $22,500; or an aggregate attachment point of less than 120% of expected claims. This subsection does not apply to: a policy or contract of medical stop–loss insurance issued or delivered before June 1, 2015, if the policy or contract maintains: a specific attachment point of no less than $10,000; and an aggregate attachment point of no less than 115% of expected claims; a renewal of a policy or contract described in item (i) of this paragraph; or a policy or contract of medical stop–loss insurance issued or delivered on or after June 1, 2015, if the policy or contract: is issued or delivered to an employer that on May 31, 2015, held a policy or contract of medical stop–loss insurance with: a specific attachment point of not less than $10,000; and an aggregate attachment point of not less than 115% of expected claims; and maintains: a specific attachment point of not less than $10,000; and an aggregate attachment point of not less than 115% of expected claims. For a stop–loss insurance policy or contract issued to a small employer, a medical stop–loss insurer may not: 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 decrease or remove stop–loss coverage for a specific individual within a small employer’s health benefit plan; or 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: physical or behavioral health, including mental illness or substance use disorder; claims experience; medical history; receipt of health care; genetic information; disability; evidence of insurability, including conditions arising out of acts of domestic violence against an employee or dependent; or any other health status–related factor as determined by the Commissioner. For a stop–loss insurance policy or contract issued to a small employer, a medical stop–loss insurer shall: guarantee rates for at least 12 months, without adjustment, unless there is a change in: the benefits provided under the small employer’s health benefit plan during the policy or contract period; the ownership and control of the small employer; or the number of covered lives by a significant percentage resulting from an event such as an acquisition or a divestiture; 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: the total costs of the policy or contract; the dates on which the policy or contract takes effect and terminates; and provisions for renewing the policy or contract; the aggregate attachment point and the specific attachment point for the policy or contract; and any limitations on coverage. 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. Nothing in this section shall be construed as: 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: 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; health maintenance organizations that provide coverage for prescription drugs on an outpatient basis under contracts that are issued or delivered in the State; 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 to the extent consistent with State and federal law, third party administrators. This section does not apply to: short–term travel or accident–only policies; short–term nonrenewable policies of not more than 3 months duration; or 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. 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: 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 includes, at a minimum, the following data elements: 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; the name and identification number of the insured, subscriber, or enrollee; the telephone number that providers may call for pharmacy benefit assistance; and 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 indicates which State agency regulates, in whole or in part, the policy or contract offered by the entity by: for an entity subject to the Administration, displaying “MIA” prominently; or for an entity subject to the Maryland Department of Health, displaying “MDH” prominently. 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. 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. 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: reissue a health insurance benefit card, prescription drug benefit card, or other technology; or provide the insured, subscriber, or enrollee with the corrective information necessary to electronically process a prescription claim. 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. The Maryland Department of Health shall adopt regulations to enable managed care organizations to comply with: the requirements of this section; and any unique requirements of the HealthChoice Program that relate to the electronic processing of claims.

This section applies to: each health insurer; each nonprofit health service plan; each health maintenance organization; and each managed care organization, as defined in § 15–101 of the Health – General Article. 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: for an entity subject to the Administration, displaying “MIA” prominently; or for an entity subject to the Maryland Department of Health, displaying “MDH” prominently. This section may not be construed to preclude an entity subject to this section from including: any other information required to be included under this article; or any information that is in addition to the information required under this section.

This section applies to: 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 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. 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. An entity subject to this section may not impose a processing fee for the electronic reimbursement or for providing payment data electronically.

In this section, “carrier” has the meaning stated in § 19–142 of the Health – General Article. 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.

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.

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. 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. 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.

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. “Annual preventive care” includes, if the service is a covered benefit: an annual child wellness visit; a routine gynecological visit; a screening test or examination for colorectal cancer, chlamydia, human papillomavirus, prostate cancer, or breast cancer; and an annual vision visit that includes a vision examination. This section applies to: 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 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 that provides covered benefits for annual preventive care shall provide coverage for the annual preventive care if: the annual preventive care is provided no more than once at any time during the plan year established in the policy or contract; and any other requirements for coverage of the annual preventive care are met. This section may not be construed to require coverage for a service not otherwise required by law.

In this section the following words have the meanings indicated. “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. “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. 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: 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 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. 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. This section may not be construed to require coverage for a service not otherwise required by law.

In this section the following words have the meanings indicated. “Carrier” means: an insurer; a nonprofit health service plan; a health maintenance organization; or any other person that provides health benefit plans subject to regulation by the State. “Group model health maintenance organization” has the meaning stated in § 19–713.6(a) of the Health – General Article. This section applies only to contracts or policies that: are issued or delivered by a carrier; and provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis. 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: after 6 p.m. and before 8 a.m.; or on weekends and national holidays. 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. 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.

In this section the following words have the meanings indicated. “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. “Ambulance service provider” means a provider of ambulance services that: is owned, operated, or under the jurisdiction of a political subdivision of the State or a volunteer fire company or volunteer rescue squad; or has contracted to provide ambulance services for a political subdivision of the State. “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. “Carrier” means: an insurer that provides benefits on an expense–incurred basis; a nonprofit health service plan; or a health maintenance organization. “Nonpreferred provider” has the meaning stated in § 14–201 of this article. “Preferred provider” has the meaning stated in § 14–201 of this article. “Preferred provider insurance policy” has the meaning stated in § 14–201 of this article. This section applies to individual or group policies or contracts issued or delivered in the State by a carrier. 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. 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. This subsection applies to an ambulance service provider that receives direct reimbursement under subsection (c) of this section. 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. An ambulance service provider or a representative of the ambulance service provider may not: 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 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. 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: 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; 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 any payment or charge for services that are not covered services. 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. 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. The Commissioner may adopt regulations to implement this section.

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. “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. “Telehealth” does not include: except as provided in paragraph (2) of this subsection, an audio–only telephone conversation between a health care provider and a patient; an electronic mail message between a health care provider and a patient; or a facsimile transmission between a health care provider and a patient. This section applies to: 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 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: 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; 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 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. The health care services appropriately delivered through telehealth shall include counseling and treatment for substance use disorders and mental health conditions. Subject to paragraph (2) of this subsection, an entity subject to this section: 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; is not required to: 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 reimburse a health care provider who is not a covered provider under the health insurance policy or contract; and 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; may impose an annual dollar maximum as permitted by federal law; and may not impose a lifetime dollar maximum. 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. The reimbursement required under subparagraph (i) of this paragraph does not include: 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 any room and board fees. 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. 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. 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. 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. 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.

In this section the following words have the meanings indicated. “Acute condition” means a medical or dental condition that: 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 has a limited duration. “Carrier” means: an insurer authorized to sell health insurance; a nonprofit health service plan; a health maintenance organization; a dental plan organization; or any other entity providing a plan of health insurance, health benefits, or health services authorized under this article or the Affordable Care Act. “Enrollee” means: a person entitled to health care benefits from a carrier; or a Program recipient who is enrolled in a managed care organization. “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. “Health benefit plan” does not include: coverage only for accident or disability insurance or any combination of accident and disability insurance; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers’ compensation or similar insurance; automobile medical payment insurance; credit–only insurance; coverage for on–site medical clinics; or 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. “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: limited scope vision benefits; benefits for long–term care, nursing home care, home health care, community–based care, or any combination of these benefits; or such other similar limited benefits as are specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act. “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: coverage only for a specified disease or illness; or hospital indemnity or other fixed indemnity insurance. “Health benefit plan” does not include the following if offered as a separate policy, certificate, or contract of insurance: Medicare Supplemental Insurance (as defined under § 1882(g)(1) of the Social Security Act); 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 similar supplemental coverage provided to coverage under a group health plan. “Health care provider” means: 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 a facility where health care is provided to patients or recipients including: a hospital, as defined in § 19–301 of the Health – General Article; a related institution as defined in § 19–301 of the Health – General Article; a freestanding ambulatory care facility as defined in § 19–3B–01 of the Health – General Article; a facility that is organized primarily to help in the rehabilitation of persons with disabilities; a home health agency as defined in § 19–901 of the Health – General Article; a hospice as defined in § 19–901 of the Health – General Article; a facility that provides radiological or other diagnostic imagery services; a medical laboratory as defined in § 17–201 of the Health – General Article; an alcohol abuse and drug abuse treatment program as defined in § 8–403 of the Health – General Article; and a Federally Qualified Health Center. “Health care provider” includes the agents, employees, officers, and directors of a health care provider described in subparagraph (i) of this paragraph. “Managed care organization” means: a certified health maintenance organization that is authorized to receive medical assistance prepaid capitation payments; a corporation that: is a managed care system that is authorized to receive medical assistance prepaid capitation payments; enrolls only Program recipients or individuals or families served under the Maryland Children’s Health Program; and is subject to the requirements of § 15–102.4 of the Health – General Article; or a prepaid dental plan that receives fees to manage dental services. “Nonparticipating provider” means a health care provider who is not on the provider panel of a carrier or managed care organization. “Participating provider” means a health care provider who is on the provider panel of a carrier or managed care organization. “Prior authorization” means a utilization management technique that: is used by carriers and managed care organizations; requires prior approval for a procedure, treatment, medication, or service before an enrollee is eligible for full payment of the benefit; and is used to determine whether the procedure, treatment, medication, or service is medically necessary. “Program recipient” means an individual who receives benefits under the Maryland Medical Assistance Program. “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. “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. “Receiving carrier or managed care organization” means: the carrier that issues the new health benefit plan when an enrollee transitions from another carrier or a managed care organization; or the managed care organization that accepts the enrollee when the enrollee transitions from another managed care organization or a carrier. “Relinquishing carrier or managed care organization” means: the carrier that issued the prior health benefit plan when an enrollee transitions to a new carrier or a managed care organization; or 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. “Serious chronic condition” means a medical or dental condition due to a disease, an illness, or any other medical or dental problem that: is serious in nature; persists without full cure or worsens over an extended period of time; and is actively managed or supervised by a health care provider to maintain remission or prevent deterioration. “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. The purpose of this section is to advance the State’s progress in: protecting Marylanders from harmful disruptions in health care services; and promoting reasonable continuity of health care for Marylanders when transitioning: from one carrier to another carrier; and between a carrier and the Maryland Medical Assistance Program or the Maryland Children’s Health Program. This section: with respect to any benefit or service that is provided through the Maryland Medical Assistance fee–for–service program: shall not apply when the enrollee is transitioning from a carrier to the Maryland Medical Assistance Program; and 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; shall apply to contracts issued or renewed on or after January 1, 2015; and 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. With respect to any benefit or service provided through the Maryland Medical Assistance fee–for–service program, this subsection shall apply: only to enrollees transitioning from the Maryland Medical Assistance Program to a carrier; and only to behavioral health and dental benefits, to the extent they are authorized by a third–party administrator. 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: the procedures, treatments, medications, or services covered by the benefits offered by the receiving carrier or managed care organization; and the following time periods: the lesser of the course of treatment or 90 days; and the duration of the three trimesters of a pregnancy and the initial postpartum visit. 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. 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: reassess and make its own determination regarding the need for continued treatment; and authorize any continued procedure, treatment, medication, or service determined to be medically necessary. 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. The services an enrollee shall be allowed to continue to receive are services for: the following conditions: acute conditions; serious chronic conditions; pregnancy; and mental health conditions and substance use disorders; and any other condition on which the nonparticipating provider and the receiving carrier or managed care organization reach agreement. Examples of conditions set forth in subparagraph (i)1A and B of this paragraph may include: bone fractures; joint replacements; heart attacks; cancer; HIV/AIDS; and organ transplants. 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. 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. 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. 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. 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. The rates and methods of payment under paragraph (3)(ii) and (iv) of this subsection shall: be subject to any State or federal requirements applicable to reimbursement for health care provider services, including: § 1302(g) of the Affordable Care Act, which applies to reimbursement rates for Federally Qualified Health Centers; and Title 19, Subtitle 2 of the Health – General Article, under which the Health Services Cost Review Commission establishes provider rates; and ensure that: an enrollee is not subject to balance billing; and 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. 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: the nonparticipating provider is not required to continue to provide the services; § 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 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. This section does not: 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 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. 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. The rate and method of payment under subparagraph (i) of this paragraph shall comply with: the prohibition on balance billing under subsection (d)(4)(ii) of this section; and any copayments, deductibles, and coinsurance requirements in the enrollee’s health benefit plan under the relinquishing carrier. 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. The requirements of this section are: in addition to any other legal, professional, or ethical obligations of a carrier or managed care organization to provide continuity of care; and 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. The Commissioner and the Secretary of Health each may adopt regulations to enforce the requirements of this section. 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: assess the implementation and efficacy of the requirements of this section; and 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. 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.

In this section the following words have the meanings indicated. “Step therapy drug” means a prescription drug or sequence of prescription drugs required to be used under a step therapy or fail–first protocol. “Step therapy exception request” means a request to override a step therapy or fail–first protocol. “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. “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. “Supporting medical information” means: a paid claim from an entity subject to this section for an insured or an enrollee; 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 other information mutually agreed on by an entity subject to this section and the prescriber of an insured or an enrollee. This section applies to: 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 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 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. An entity subject to this section may not impose a step therapy or fail–first protocol on an insured or an enrollee if: the step therapy drug has not been approved by the U.S. Food and Drug Administration for the medical condition being treated; or a prescriber provides supporting medical information to the entity that a prescription drug covered by the entity: was ordered by a prescriber for the insured or enrollee within the past 180 days; and based on the professional judgment of the prescriber, was effective in treating the insured’s or enrollee’s disease or medical condition. Subsection (c) of this section may not be construed to require coverage for a prescription drug that is not: covered by the policy or contract of an entity subject to this section; or otherwise required by law to be covered. 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: the prescription drug is used to treat the insured’s or enrollee’s stage four advanced metastatic cancer; and use of the prescription drug is: 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 supported by peer–reviewed medical literature; 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 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; use of the prescription drug is: 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 supported by peer–reviewed medical literature; and the prescription drug is covered under the terms of the policy or contract of the insured or enrollee. An entity subject to this section shall establish a process for requesting an exception to a step therapy or fail–first protocol that is: 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; easily accessible to the prescriber; and posted on the entity’s website. 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: the step therapy drug is contraindicated or will likely cause an adverse reaction to the insured or enrollee; 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; 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 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: is in the same pharmacologic class or has the same mechanism of action as the step therapy drug; and was discontinued by the prescriber due to lack of efficacy or effectiveness, diminished effect, or an adverse event. 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. An enrollee or insured may appeal a step therapy exception request denial in accordance with Subtitle 10A or Subtitle 10B of this title. This subsection may not be construed to: prevent: 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 a health care provider from prescribing a prescription drug that is determined to be medically appropriate; or 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. An entity subject to this section may use an existing step therapy exception process that satisfies the requirements under this subsection.

In this section, “participation agreement” means a contract that: is executed by a payor or program administrator and other participating entities; and describes the requirements for participation in a payment model subject to this section. This section applies only to a payment model described in § 1–302(d)(12) of the Health Occupations Article: that applies to individuals covered under health insurance; and under which there is cash compensation. 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. 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. 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: is insurance business; and violates this article or a regulation adopted under this article. 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. The Commissioner shall hold a hearing before issuing an order under paragraph (1) of this subsection. The Commissioner shall give written notice of the hearing to the filer at least 10 days before the hearing. The notice shall specify the matters to be considered at the hearing. If the compensation arrangement between a health care practitioner and a health care entity changes during its term: the filer shall submit a revised filing to the Commissioner for review of the changes; and the Commissioner shall make a new determination, as provided under subsection (d) of this section. A filing under subsection (c) of this section is subject to the fee required under § 2–112(a)(13) of this article.

In this section the following words have the meanings indicated. “Carrier” means: an insurer that holds a certificate of authority in the State and provides health insurance in the State; a health maintenance organization that is licensed to operate in the State; a nonprofit health service plan that is licensed to operate in the State; or any other person or organization that provides health benefit plans subject to State insurance regulation. “Core treatment” means a standard treatment or course of treatment, therapy, service, or intervention indicated by generally recognized independent standards of current medical practice. “Health benefit plan” means: for a large group or blanket plan, a health benefit plan as defined in § 15–1401 of this title; for a small group plan, a health benefit plan as defined in § 15–1201 of this title; for an individual plan: a health benefit plan as defined in § 15–1301(l) of this title; or an individual health benefit plan as defined in § 15–1301(o) of this title; short–term limited duration insurance as defined in § 15–1301(s) of this title; or a student health plan as defined in § 15–1318(a) of this title. “Medical/surgical benefits” has the meaning stated in 45 C.F.R. § 146.136(a) and 29 C.F.R. § 2590.712(a). “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: 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: 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 are listed in the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders; and 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. “Mental health benefits” does not include medical/surgical benefits or substance use disorder benefits. “Nonquantitative treatment limitation” means treatment limitations as defined in 45 C.F.R. § 146.136(a) and 29 C.F.R. § 2590.712(a). “Parity Act” means the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, as amended. “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. “Parity Act classification” means: inpatient in–network benefits; inpatient out–of–network benefits; outpatient in–network benefits; outpatient out–of–network benefits; prescription drug benefits; and emergency care benefits. “Product” has the meaning stated in § 15–1309(a)(3) of this title. “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: 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: 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 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 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. “Substance use disorder benefits” does not include medical/surgical benefits or mental health benefits. This section applies to a carrier that delivers or issues for delivery a health benefit plan in the State. Each carrier subject to this section shall: 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; 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; 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 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; provide the comparative analysis, including the evaluation of relevant data, for each nonquantitative treatment limitation requested by the Commissioner within: 15 working days after a written request; or if adopted by the federal government, less than 15 working days to align with the federal rule or regulation; 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 submit the reports required under paragraph (2) of this subsection. 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. The report submitted under paragraph (2) of this subsection shall include the following information: 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; 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 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. 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: the statement required under paragraph (3)(iii) of this subsection shall note the exception and identify the plan; and the carrier shall submit a separate comparative analysis for the selected nonquantitative treatment limitations for the plan. In selecting the nonquantitative treatment limitations required to be included for each reporting period, the Commissioner: shall prioritize the nonquantitative treatment limitations identified by the Commissioner as having the greatest impact on member access to care; shall review the same subset of nonquantitative treatment limitations for each carrier report; and 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. Of the five selected nonquantitative treatment limitations: not more than two may be for utilization review; and at least one must be for network composition, including reimbursement rate setting. A finding of noncompliance for a product shall apply to all plans within the product. 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: 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 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. 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: written; and in operation. The comparative analysis of the nonquantitative treatment limitations selected under subsection (c)(5) of this section shall: 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; 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; 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 include all information required under the Parity Act and any State regulations adopted under subsection (o) of this section. 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. 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. 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: 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 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. 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. In providing the analysis required under subsection (d) of this section, a carrier shall: identify the factors used to determine that a nonquantitative treatment limitation will apply to a benefit, including: the sources for the factors; and if a factor was given more weight than another, the reason for the difference in weighting; identify and define the specific evidentiary standards used to define the factors and any other evidence relied on in designing each nonquantitative treatment limitation; 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; 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; 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; 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; 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 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: the criteria for a medical necessity determination; reasons for a denial of benefits; and 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. The Commissioner shall: develop additional standardized data templates: to evaluate the comparative analysis of nonquantitative treatment limitations in operation; and that meet or exceed any minimum requirements for data reporting specified in federal regulations; require each carrier subject to this section to submit: 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 a separate data template for any plans described in subsection (c)(4) of this section; and post the data templates on the Administration’s website for a comment period of not less than 30 days before adoption. The reports required under this section shall: 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; be submitted by the carrier that issues or delivers the product; be prepared in coordination with any entity the carrier contracts with to provide mental health benefits and substance use disorder benefits; contain a statement, signed by a corporate officer, attesting to the accuracy of the information contained in the report; 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 exclude any identifying information of any plan member. 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: identify the particular information the disclosure of which the carrier requests be denied; and cite the statutory authority under the Public Information Act that authorizes denial of access to the information. 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. 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. 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. The Commissioner shall: 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; 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 within 90 days after the notice of noncompliance is issued, allow the carrier to: 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 reprocess any claims that were improperly denied, in whole or in part, because of the noncompliance. The Commissioner may require carriers to complete data templates for a nonquantitative treatment limitation more frequently than every 2 years. If the Commissioner finds that the carrier failed to submit a complete report required under this section, the Commissioner may: take action authorized under paragraph (2) of this subsection; in accordance with § 2–208 of this article, charge the carrier for any additional expenses incurred by the Commissioner to review additional reports; impose a penalty for each day that the carrier fails to submit information required by the Commissioner to evaluate compliance; or impose any penalty or take any action as authorized: for an insurer, nonprofit health service plan, or any other person subject to this section, under this article; or for a health maintenance organization, under this article or the Health – General Article. 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: 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: modify the conduct or practice as specified by the Commissioner; cease the conduct or practice; or submit periodic data related to the conduct or practice; or subject to paragraph (3) of this subsection, require the carrier to perform a new comparative analysis. 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: use applicable quantitative thresholds for the evidentiary standard; or 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. Subsection (i)(1)(iii) of this section does not apply to the failure of a carrier to submit a complete report. 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: issue an administrative order that requires: the carrier or an entity delegated by the carrier to cease the noncompliant conduct or practice; or the carrier to provide a payment that has been denied improperly because of the noncompliance; or impose any other penalty or take any action as authorized: for an insurer, nonprofit health service plan, or any other person subject to this section, under this article; or for a health maintenance organization, under this article or the Health – General Article. 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: in any review conducted by the Commissioner under this section; or in any complaint investigation or market conduct action undertaken by the Commissioner that involves the application of the Parity Act. 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. Subsection (i)(1)(iii) of this section does not apply to a carrier that fails to submit complete Parity Act compliance information. 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. The Commissioner shall create: a standard form for entities to submit the reports in accordance with subsection (g)(1) of this section; and a summary form for entities to post to their websites in accordance with subsection (g)(5) of this section. 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.

In this section the following words having the meanings indicated. “Health savings account” has the meaning stated in § 223 of the Internal Revenue Code. “High deductible health plan” has the meaning stated in § 223 of the Internal Revenue Code. A health savings account is established on the first day that an individual becomes covered by a high deductible health plan. 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. 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.

In this section the following words have the meanings indicated. “Blanket health insurance” means the form of health insurance described in § 15–305 of this title. “Health benefit plan” means: an individual health benefit plan as defined in § 15–1301(o) of this title; a health benefit plan as defined in § 15–1201 of this title; or a health benefit plan as defined in § 15–1401 of this title. “Short–term limited duration insurance” has the meaning stated in § 15–1301(s) of this title. 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. 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. The Commissioner may enforce this section under any applicable provisions of this article.

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