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<section article="gin" article_name="Insurance" number="15-121" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions">
  <level label="a">
    <level label="1">
      <text>In this section the following words have the meanings indicated.</text>
    </level>
    <level label="2">
      <text>“Carrier” means:</text>
      <level label="i">
        <text>an insurer;</text>
      </level>
      <level label="ii">
        <text>a nonprofit health service plan;</text>
      </level>
      <level label="iii">
        <text>a health maintenance organization;</text>
      </level>
      <level label="iv">
        <text>a dental plan organization;</text>
      </level>
      <level label="v">
        <text>any person or entity acting as a third party administrator; or</text>
      </level>
      <level label="vi">
        <text>except for a managed care organization as defined in Title 15, Subtitle 1 of the Health – General Article, any other person that provides health benefit plans subject to regulation by the State.</text>
      </level>
    </level>
    <level label="3">
      <text>“Contract” means any written agreement between a provider and a carrier for the provider to render health care services to enrollees of the carrier.</text>
    </level>
    <level label="4">
      <text>“Enrollee” means any person or subscriber entitled to health care benefits from a carrier.</text>
    </level>
    <level label="5">
      <text>“Health care services” means a health or medical care procedure or service rendered by a provider that:</text>
      <level label="i">
        <text>provides testing, diagnosis, or treatment of a human disease or dysfunction; or</text>
      </level>
      <level label="ii">
        <text>dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction.</text>
      </level>
    </level>
    <level label="6">
      <level label="i">
        <text>“Provider” means a person or entity licensed, certified, or otherwise authorized under the Health Occupations Article or the Health – General Article to provide health care services.</text>
      </level>
      <level label="ii">
        <text>“Provider” includes:</text>
        <level label="1">
          <text>a health care facility;</text>
        </level>
        <level label="2">
          <text>a pharmacy;</text>
        </level>
        <level label="3">
          <text>a professional services corporation;</text>
        </level>
        <level label="4">
          <text>a partnership;</text>
        </level>
        <level label="5">
          <text>a limited liability company;</text>
        </level>
        <level label="6">
          <text>a professional office; and</text>
        </level>
        <level label="7">
          <text>any other entity licensed or authorized by law to provide or deliver professional health care services through or on behalf of a provider.</text>
        </level>
      </level>
    </level>
  </level>
  <level label="b">
    <text>This section applies to a carrier that provides health care services to enrollees, or otherwise makes health care services available to enrollees, through contracts with providers.</text>
  </level>
  <level label="c">
    <level label="1">
      <text>Each carrier shall identify and disclose in layman’s terms in its enrollment sales materials the reimbursement methodology or methodologies the carrier uses to reimburse physicians for health care services rendered to enrollees, including capitation, case rates, discounted fee-for-service, and fee-for-service reimbursement methodologies.</text>
    </level>
    <level label="2">
      <text>The Maryland Health Care Commission shall develop a uniform definition in layman’s terms of each reimbursement methodology required to be disclosed and identified by carriers under paragraph (1) of this subsection, including a representative example of a typical capitation arrangement between a carrier and a physician.</text>
    </level>
  </level>
  <level label="d">
    <level label="1">
      <text>In addition to the requirements of subsection (c)(1) of this section, each carrier shall disclose in its enrollment sales materials the distribution of each $100 it receives in premium dollars from enrollees for the preceding calendar year, for which data are available.</text>
    </level>
    <level label="2">
      <text>The disclosure required under paragraph (1) of this subsection shall be in the form of a pie chart or bar graph with descriptive terms and in layman’s terms that identifies consistent with the National Association of Insurance Commissioners’ health maintenance organization annual statement (“orange form”):</text>
      <level label="i">
        <text>the proportion of every $100 in premium dollars that the carrier uses to pay providers for the direct provision of health care services to enrollees, including what proportion is for direct medical care expenses; and</text>
      </level>
      <level label="ii">
        <text>the proportion of every $100 in premium dollars that the carrier uses to pay for plan administration.</text>
      </level>
    </level>
  </level>
</section>
