This section applies to insurers and nonprofit health service plans that provide hospital benefits in the State under individual, group, or blanket health insurance policies. Each entity subject to this section that offers benefits to an insured or beneficiary who uses designated low-cost hospitals, that are different from the benefits offered when other hospitals are used, shall base its designation of a low-cost hospital on information that: excludes the reasonable cost of medical education and of uncompensated care as determined by the Health Services Cost Review Commission; excludes the cost associated with a shock trauma facility as determined by the Health Services Cost Review Commission; excludes the amount in rates approved by the Health Services Cost Review Commission for undergraduate nursing education; excludes from consideration each hospital that is determined by the Maryland Health Care Commission to be a sole community provider; and compares hospitals on a regional basis, unless the entity demonstrates to the satisfaction of the Commissioner that a statewide comparison is more appropriate. An entity subject to this section that provides hospital benefits under subsection (b) of this section may not subsidize those benefits from premiums earned by other benefit plans, programs, or policies.

This section applies to each individual, group, or blanket health insurance policy or certificate that is delivered or issued for delivery in the State by an insurer or nonprofit health service plan on or after July 2, 1969. A policy or certificate subject to this section may not exclude payments or benefits for the treatment of tuberculosis, mental illness, or another illness covered under the policy or certificate because treatment is received in a hospital or other institution of the State or of a county or municipal corporation of the State, whether or not the hospital or other institution is deemed charitable.

If the Maryland Department of Health notifies an insurer or nonprofit health service plan that the Department has paid for or provided services to an individual who is covered under an individual, group, or blanket health insurance policy or contract that the insurer or nonprofit health service plan issued, delivered, or renewed in the State, the insurer or nonprofit health service plan shall reimburse the Department for the cost of the services, regardless of any provision in the health insurance policy or contract that requires payment to the policyholder, subscriber, or another payee. The benefits payable to the Maryland Department of Health under this section are limited to those benefits available under the terms and conditions of the health insurance policy or contract for the services paid for or provided by the Department. An insurer or nonprofit health service plan is not required to make payment to the Department under this section if, before receiving notice from the Department under subsection (a) of this section, the insurer or nonprofit health service plan has paid the benefits available under the health insurance policy or contract in good faith and in accordance with the terms and conditions of the policy or contract. Notwithstanding any other provision of a health insurance policy, contract, or certificate, an insurer or nonprofit health service plan may not refuse to reimburse the Maryland Department of Health because of the manner, form, or date of a claim for reimbursement if, within 2 years after the date of the service for which reimbursement is sought, the Department provides to the insurer or nonprofit health service plan sufficient information to determine the liability of the insurer or nonprofit health service plan.

Each authorized insurer, nonprofit health service plan, and fraternal benefit society, and each managed care organization that is authorized to receive Medicaid prepaid capitation payments under Title 15, Subtitle 1 of the Health – General Article, shall: pay hospitals for hospital services rendered on the basis of the rate approved by the Health Services Cost Review Commission; and comply with the applicable terms and conditions of the all–payer model contract, as defined in § 19–201 of the Health – General Article.

On or before March 1 of each year, an annual report that meets the specifications of paragraph (2) of this subsection shall be submitted to the Commissioner by, as applicable in accordance with regulations adopted by the Commissioner, each managed care organization that is authorized to receive Medicaid prepaid capitation payments under Title 15, Subtitle 1 of the Health – General Article. The annual report required under this subsection shall: be submitted in a form required by the Commissioner; and include for the preceding calendar year the following data for all health benefit plans specific to the State: premiums written; premiums earned; total amount of incurred claims including reserves for claims incurred but not reported at the end of the previous year; total amount of incurred expenses, including commissions, acquisition costs, general expenses, taxes, licenses, and fees, estimated if necessary; loss ratio; and expense ratio. The data required under paragraph (2) of this subsection shall be reported in the aggregate. The Commissioner, in consultation with the Secretary of Health, shall establish and adopt by regulation a methodology to be used in the annual report that ensures a clear separation of all medical and administrative expenses whether incurred directly or through a subcontractor. The Commissioner may conduct an examination to ensure that an annual report submitted under this subsection is accurate. Before a managed care organization may enroll a medical assistance program recipient, the managed care organization shall provide a business plan to the Commissioner. As part of the annual report required under subsection (a) of this section, a managed care organization shall: provide a list of the total compensation from the managed care organization, including all cash and deferred compensation, stock, and stock options in addition to salary, of each member of the board of directors of the managed care organization, and each senior officer of the managed care organization or any subsidiary of the managed care organization as designated by the Commissioner; and provide any other information or documents necessary for the Commissioner to ensure compliance with this subsection and subsections (a)(3)(iii) and (c)(5), (6), and (7) of this section and for the Secretary of Health to carry out Title 15, Subtitle 1 of the Health – General Article. Individual health insurance coverage and health insurance coverage offered in the small group and large group markets, as those terms are defined in the federal Public Health Service Act, issued or delivered in the State by an authorized insurer, nonprofit health service plan, or health maintenance organization shall comply with the loss ratio requirements of sections 1001(5) and 10101(f) of the Affordable Care Act, which amend section 2718 of the Public Health Service Act. The provisions of subparagraph (i) of this paragraph do not apply to coverage for excepted benefits, as defined in 45 C.F.R. § 146.145(c). The Commissioner may require an insurer, a nonprofit health service plan, or a health maintenance organization to file new rates if the loss ratio reported in the manner required under 45 C.F.R. § 158 is less than that required under subparagraph (i) of this paragraph. The authority of the Commissioner under paragraph (1) of this subsection to require an insurer, nonprofit health service plan, or health maintenance organization to file new rates based on loss ratio: is in addition to any other authority of the Commissioner under this article to require that rates not be excessive, inadequate, or unfairly discriminatory; and does not limit any existing authority of the Commissioner to determine whether a rate is excessive. In determining whether to require an insurer to file new rates under this subsection, the Commissioner may consider the amount of health insurance premiums earned in the State on individual policies in proportion to the total health insurance premiums earned in the State for the insurer. The insurer shall provide to the Commissioner the information necessary to determine the proportion of individual health insurance premiums to total health insurance premiums as provided under this paragraph. The Secretary of Health, in consultation with the Commissioner and in accordance with their memorandum of understanding, may adjust capitation payments for a managed care organization or for the Maryland Medical Assistance Program of a managed care organization that is a certified health maintenance organization if the loss ratio is less than 85%. A loss ratio reported under paragraph (4) of this subsection shall be calculated separately and may not be part of another loss ratio reported under this section. Any rebate received by a managed care organization may not be considered part of the loss ratio of the managed care organization. If the Secretary of Health adjusts capitation payments for a managed care organization or a certified health maintenance organization under paragraph (4) of this subsection, the managed care organization or certified health maintenance organization may: appeal the decision of the Secretary to the Board of Review established under Title 2, Subtitle 2 of the Health – General Article; and take any further appeal allowed by the Administrative Procedure Act under Title 10, Subtitle 2 of the State Government Article. The Secretary of Health shall publish in a conspicuous manner on the Web site of the Maryland Department of Health: the loss ratio, as determined by the Maryland Department of Health for each managed care organization participating in the medical assistance program, for each year during the most recent 3–year period; for each year during the 3–year period, the amount to be returned to the medical assistance program, if any, from a managed care organization for failing to meet the loss ratio requirement under paragraph (4) of this subsection; and any amount due to or received by the Maryland Department of Health from a managed care organization for each year during the 3–year period. Each insurer, nonprofit health service plan, and health maintenance organization shall provide annually to each contract holder a written statement of the loss ratio for a health benefit plan as submitted to the Commissioner under this section. On or before March 1 of each year, unless, for good cause shown, the Commissioner extends the time for a reasonable period, each managed care organization shall file with the Commissioner a report that shows the financial condition of the managed care organization on the last day of the preceding calendar year and any other information that the Commissioner requires by bulletin or regulation. At any time, the Commissioner may require a managed care organization to file an interim statement containing the information that the Commissioner considers necessary. The annual and interim reports shall be filed in a form required by the Commissioner. Except as provided in paragraph (3) of this subsection on or before June 1 of each year, each managed care organization shall file with the Commissioner an audited financial report for the preceding calendar year. The audited financial report shall: be filed in a form required by the Commissioner; and be certified by an audit of an independent certified public accountant. With 90 days’ advance notice, the Commissioner may require a managed care organization to file an audited financial report earlier than the date specified in paragraph (2) of this subsection. Each financial report filed under this section is a public record.