In this subtitle the following words have the meanings indicated. “Appeal” means a protest filed by a member, a member’s representative, or a health care provider with a carrier under its internal appeal process regarding a coverage decision concerning a member. “Appeal decision” means a final determination by a carrier that arises from an appeal filed with the carrier under its appeal process regarding a coverage decision concerning a member. “Carrier” means a person that offers a health benefit plan and is: an authorized insurer that provides health insurance in the State; a nonprofit health service plan; a health maintenance organization; a dental plan organization; a self–funded student health plan operated by an independent institution of higher education, as defined in § 10–101 of the Education Article, that provides health care to its students and their dependents; or except for a managed care organization, as defined in Title 15, Subtitle 1 of the Health – General Article, any other person that offers a health benefit plan subject to regulation by the State. “Complaint” means a protest filed with the Commissioner involving a coverage decision other than that which is covered by Subtitle 10A of this title. “Coverage decision” means: an initial determination by a carrier or a representative of the carrier that results in noncoverage of a health care service; a determination by a carrier that an individual is not eligible for coverage under the carrier’s health benefit plan; or any determination by a carrier that results in the rescission of an individual’s coverage under a health benefit plan. “Coverage decision” includes nonpayment of all or any part of a claim. “Coverage decision” does not include: an adverse decision as defined in § 15–10A–01(b) of this title; or a pharmacy inquiry. “Designee of the Commissioner” means any person to whom the Commissioner has delegated the authority to review and decide complaints filed under this subtitle, including an administrative law judge to whom the authority to conduct a hearing has been delegated for recommended or final decision. “Health benefit plan” means: a hospital or medical policy or contract, including a policy or contract issued under a multiple employer trust or association; a hospital or medical policy or contract issued by a nonprofit health service plan; a health maintenance organization contract; or a dental plan organization contract. “Health benefit plan” does not include one or more, or any combination of the following: long–term care insurance; disability insurance; accidental travel and accidental death and dismemberment insurance; credit health insurance; a health benefit plan issued by a managed care organization, as defined in Title 15, Subtitle 1 of the Health – General Article; disease–specific insurance; or fixed indemnity insurance. “Health care provider” means: an individual who is licensed under the Health Occupations Article to provide health care services in the ordinary course of business or practice of a profession and is a treating provider of the member; or a hospital, as defined in § 19–301 of the Health – General Article. “Health care service” means a health or medical care procedure or service rendered by a health care 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. “Member” means: a person entitled to health care services under a policy, plan, or contract issued or delivered in the State by a carrier; or with regard to an individual who is determined by a carrier not to be eligible for a health benefit plan, an individual who has applied for coverage under a health benefit plan. “Member” includes: a subscriber; and unless preempted by federal law, a Medicare recipient. “Member” does not include a Medicaid recipient. “Member’s representative” means an individual who has been authorized by the member to file an appeal or a complaint on behalf of the member. “Pharmacy benefits manager” has the meaning stated in § 15–1601 of this title. “Pharmacy inquiry” means an inquiry submitted by a pharmacist or pharmacy on behalf of a member to a carrier or a pharmacy benefits manager at the point of sale about the scope of pharmacy coverage, pharmacy benefit design, or formulary under a health benefit plan.

Each carrier shall establish an internal appeal process for use by its members, its members’ representatives, and health care providers to dispute coverage decisions made by the carrier. The carrier may use the internal grievance process established under Subtitle 10A of this title to comply with the requirement of paragraph (1) of this subsection. A carrier under this section shall render a final decision in writing to a member, a member’s representative, and a health care provider acting on behalf of the member within 60 working days after the date on which the appeal is filed. Except as provided in subsection (d) of this section, the carrier’s internal appeal process shall be exhausted prior to filing a complaint with the Commissioner under this subtitle. A member, a member’s representative, or a health care provider filing a complaint on behalf of a member may file a complaint with the Commissioner without first filing an appeal with a carrier only if the coverage decision involves an urgent medical condition, as defined by regulation adopted by the Commissioner, for which care has not been rendered. Within 30 calendar days after a coverage decision has been made, a carrier shall send a written notice of the coverage decision to the member and the member’s representative, if any, and, in the case of a health maintenance organization, the treating health care provider. Notice of the coverage decision required to be sent under paragraph (1) of this subsection shall: state in detail in clear, understandable language, the specific factual bases for the carrier’s decision; and include the following information: that the member, the member’s representative, or a health care provider acting on behalf of the member has a right to file an appeal with the carrier; that the member, the member’s representative, or a health care provider acting on behalf of the member may file a complaint with the Commissioner without first filing an appeal, if the coverage decision involves an urgent medical condition for which care has not been rendered; the Commissioner’s address, telephone number, and facsimile number; that the Health Advocacy Unit is available to assist the member or the member’s representative in both mediating and filing an appeal under the carrier’s internal appeal process; and the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit. Within 30 calendar days after the appeal decision has been made, each carrier shall send to the member, the member’s representative, and the health care provider acting on behalf of the member a written notice of the appeal decision. Notice of the appeal decision required to be sent under paragraph (1) of this subsection shall: state in detail in clear, understandable language the specific factual bases for the carrier’s decision; and include the following information: that the member, the member’s representative, or a health care provider acting on behalf of the member has a right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s appeal decision; the Commissioner’s address, telephone number, and facsimile number; a statement that the Health Advocacy Unit is available to assist the member in filing a complaint with the Commissioner; and the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit. The Commissioner may request the member that filed the complaint or a legally authorized designee of the member to sign a consent form authorizing the release of the member’s medical records to the Commissioner or the Commissioner’s designee that are needed in order for the Commissioner to make a final decision on the complaint. A carrier shall have the burden of persuasion that its coverage decision or appeal decision, as applicable, is correct: during the review of a complaint by the Commissioner or a designee of the Commissioner; and in any hearing held in accordance with Title 10, Subtitle 2 of the State Government Article to contest a final decision of the Commissioner made and issued under this subtitle. As part of the review of a complaint, the Commissioner or a designee of the Commissioner may consider all of the facts of the case and any other evidence that the Commissioner or designee of the Commissioner considers appropriate. The Commissioner shall: make and issue in writing a final decision on all complaints filed with the Commissioner under this subtitle that are within the Commissioner’s jurisdiction; and provide notice in writing to all parties to a complaint of the opportunity and time period for requesting a hearing to be held in accordance with Title 10, Subtitle 2 of the State Government Article to contest a final decision of the Commissioner made and issued under this subtitle.

It is a violation of this subtitle for a carrier to fail to fulfill the carrier’s obligations to provide or reimburse for health care services specified in the carrier’s policies or contracts with members. If, in rendering a coverage decision or appeal decision, a carrier fails to fulfill the carrier’s policies or contracts with members, the Commissioner may: issue an administrative order that requires the carrier to: cease inappropriate conduct or practices by the carrier or any of the personnel employed or associated with the carrier; fulfill the carrier’s contractual obligations; provide a health care service or payment that has been denied improperly; or take appropriate steps to restore the carrier’s ability to provide a health care service or payment that is provided under a contract; or impose any penalty or fine or take any action as authorized: for an insurer, nonprofit health service plan, or dental plan organization, under this article; or for a health maintenance organization, under the Health - General Article or under this article.

The Commissioner may adopt any necessary regulations to carry out the provisions of this subtitle.

A carrier shall provide the notices required to be provided to members under this subtitle in a culturally and linguistically appropriate manner as described in the Affordable Care Act.