<?xml version='1.0' encoding='utf-8'?>
<section article="gin" article_name="Insurance" number="15-127" title_number="15" title_name="Health Insurance" subtitle_number="1" subtitle_name="General Provisions">
  <level label="a">
    <level label="1">
      <text>In this section the following words have the meanings indicated.</text>
    </level>
    <level label="2">
      <level label="i">
        <text>“Behavioral health care administrative expenses” means any expenses that are for administrative functions including:</text>
        <level label="1">
          <text>billing and collection expenses;</text>
        </level>
        <level label="2">
          <text>accounting and financial reporting expenses;</text>
        </level>
        <level label="3">
          <text>quality assurance and utilization management program or activity expenses;</text>
        </level>
        <level label="4">
          <text>promotion and marketing expenses;</text>
        </level>
        <level label="5">
          <text>taxes, fees, and assessments;</text>
        </level>
        <level label="6">
          <text>legal expenses;</text>
        </level>
        <level label="7">
          <text>salary expenses for employees that are not related to the delivery of behavioral health care services to patients;</text>
        </level>
        <level label="8">
          <text>computer expenses;</text>
        </level>
        <level label="9">
          <text>provider credentialing;</text>
        </level>
        <level label="10">
          <text>collection and administrative review of treatment plans;</text>
        </level>
        <level label="11">
          <text>auditing the financial report submitted to the Commissioner under this section;</text>
        </level>
        <level label="12">
          <text>debt payment and debt service; and</text>
        </level>
        <level label="13">
          <text>other general and administrative expenses.</text>
        </level>
      </level>
      <level label="ii">
        <text>“Behavioral health care administrative expenses” does not include expenses incurred for behavioral health care services.</text>
      </level>
    </level>
    <level label="3">
      <level label="i">
        <text>“Behavioral health care services” means procedures or services rendered by a health care provider for the treatment of mental illness, emotional disorders, drug abuse, or alcohol abuse.</text>
      </level>
      <level label="ii">
        <text>“Behavioral health care services” includes any quality assurance or utilization management activities or treatment plan reviews that are clinical in nature.</text>
      </level>
      <level label="iii">
        <text>“Behavioral health care services” does not include administrative functions.</text>
      </level>
    </level>
    <level label="4">
      <text>“Carrier” means:</text>
      <level label="i">
        <text>a health insurer;</text>
      </level>
      <level label="ii">
        <text>a nonprofit health service plan;</text>
      </level>
      <level label="iii">
        <text>a health maintenance organization;</text>
      </level>
      <level label="iv">
        <text>a preferred provider organization;</text>
      </level>
      <level label="v">
        <text>a third party administrator; or</text>
      </level>
      <level label="vi">
        <text>except for a managed care organization as defined in Title 15, Subtitle 1 of the Health – General Article, any other person that provides health benefit plans subject to regulation by the State.</text>
      </level>
    </level>
    <level label="5">
      <text>“Direct behavioral health care expenses” means any payment to a health care provider by a managed behavioral health care organization for the provision of behavioral health care services to a member.</text>
    </level>
    <level label="6">
      <text>“Direct payments” means the money that a carrier disburses to a managed behavioral health care organization for the provision of behavioral health care services to a member.</text>
    </level>
    <level label="7">
      <text>“Managed behavioral health care organization” means a company, organization, private review agent, or subsidiary that:</text>
      <level label="i">
        <text>contracts with a carrier to provide, undertake to arrange, or administer behavioral health care services to members; or</text>
      </level>
      <level label="ii">
        <text>otherwise makes behavioral health care services available to members through contracts with health care providers.</text>
      </level>
    </level>
    <level label="8">
      <level label="i">
        <text>“Member” means an individual entitled to behavioral health care services from a carrier or a managed behavioral health care organization under a policy or plan issued or delivered in the State.</text>
      </level>
      <level label="ii">
        <text>“Member” includes a subscriber.</text>
      </level>
    </level>
    <level label="9">
      <text>“Provider” means a person licensed, certified, or otherwise authorized under the Health Occupations Article or the Health – General Article to provide health care services.</text>
    </level>
  </level>
  <level label="b">
    <text>This section does not apply to a person that, for an administrative fee only, solely arranges a provider panel for a carrier for the provision of behavioral health care services on a discounted fee–for–service basis.</text>
  </level>
  <level label="c">
    <level label="1">
      <text>A carrier that owns or contracts with a managed behavioral health care organization shall distribute to its members at the time of enrollment an explanation of:</text>
      <level label="i">
        <text>the specific behavioral health care services covered and the specific exclusions under the member’s contract;</text>
      </level>
      <level label="ii">
        <text>the member’s responsibilities for obtaining behavioral health care services;</text>
      </level>
      <level label="iii">
        <text>the reimbursement methodology that the carrier and managed behavioral health care organization use to reimburse providers for behavioral health care services; and</text>
      </level>
      <level label="iv">
        <text>the procedure that a member must utilize when attempting to obtain behavioral health care services outside the network of providers used by the carrier or managed behavioral health care organization.</text>
      </level>
    </level>
    <level label="2">
      <text>The explanation that a carrier is required to distribute under paragraph (1)(iii) of this subsection shall be consistent with § 15–121(c) of this subtitle.</text>
    </level>
    <level label="3">
      <text>A carrier that owns or contracts with a managed behavioral health care organization shall:</text>
      <level label="i">
        <text>include information on behavioral health care providers in the list of providers on the carrier’s provider panel required under § 15–112(n) of this subtitle; and</text>
      </level>
      <level label="ii">
        <text>provide the same information on behavioral health care providers that is required for other providers under § 15–112(n) of this subtitle.</text>
      </level>
    </level>
    <level label="4">
      <level label="i">
        <text>A carrier that contracts with a managed behavioral health care organization shall require the managed behavioral health care organization to provide to the carrier on an annual basis a report on the direct behavioral health care expenses of the managed behavioral health care organization.</text>
      </level>
      <level label="ii">
        <text>The report required under subparagraph (i) of this paragraph shall be made publicly available by the carrier.</text>
      </level>
    </level>
  </level>
  <level label="d">
    <level label="1">
      <text>Each carrier that provides behavioral health care services through a company owned wholly or in part by the carrier or through a contract with a managed behavioral health care organization shall complete and maintain a form developed by the Commissioner that includes the following information:</text>
      <level label="i">
        <text>the carrier’s direct payments for the preceding calendar year;</text>
      </level>
      <level label="ii">
        <text>the information required to be collected by a carrier under subsection (c)(4) of this section; and</text>
      </level>
      <level label="iii">
        <text>reported separately from the information required under item (ii) of this paragraph, the carrier’s total expenses for quality assurance and utilization management activities and treatment plan reviews that are clinical in nature.</text>
      </level>
    </level>
    <level label="2">
      <text>The Commissioner shall develop a form to implement the requirements of this subsection.</text>
    </level>
  </level>
  <level label="e">
    <level label="1">
      <text>Each carrier required under subsection (d) of this section to complete and maintain the form developed by the Commissioner shall make copies of the form publicly available to an individual, enrollee, or member, upon request.</text>
    </level>
    <level label="2">
      <text>A carrier that is required to make a form publicly available to an individual, enrollee, or member under paragraph (1) of this subsection may charge:</text>
      <level label="i">
        <text>a reasonable preparation fee not to exceed $15 for each form requested; and</text>
      </level>
      <level label="ii">
        <text>the actual cost for any postage and handling required to provide copies of the requested forms.</text>
      </level>
    </level>
  </level>
  <level label="f">
    <text>The Commissioner may adopt regulations to carry out the provisions of this section.</text>
  </level>
</section>
