In this chapter, the following terms have the meanings indicated. Terms Defined. “Accounting and Reporting System for Hospitals” means the system originally adopted by the Commission in 1973 and as amended which is in effect at the time the System is referred to in these regulations. The System is also referred to as “the Rate Review System”, or “the Accounting and Budget Manual for Fiscal and Operating Management”. “Beneficial owner” means that person who ultimately benefits or suffers losses from the operation of the firm or has a vested interest in it, and includes, but is not limited to, limited partners, beneficiaries of voting or other trusts, and limited term and remaindermen beneficiaries or owners. “Firm” means a partnership, corporation or other business professional, or academic entity, and, in the case of sole proprietors or practitioners, the trustee himself. “Notify in writing” or “written notification” means personal delivery to the person to be notified, or mailing through the United States Postal Services, by registered or certified mail, return receipt requested to the person to be notified. “Officer” means: An individual who is elected to office pursuant to a resolution of the governing board of the hospital or related institution, to fill a position defined in the bylaws of the hospital or related institution; or An individual who, although not specifically designated as an “officer” administers the policies of the hospital or related institution, and has the authority and performs the duties in the management of the property and affairs of the hospital or related institution as may be provided in the bylaws. “Partner” means any partner who has voting power or management or policy responsibilities, regardless of restrictions thereon, but excludes limited partners or other partners who have no vote in or management or policy responsibilities as to the partnership. “Section 556 hospitals” or “hospitals” means all hospitals as defined in Article 43, §556, Annotated Code of Maryland. “Section 556 nursing homes” or “nursing homes” or “Section 556 care homes” or “care homes” means all nursing homes or care homes as defined in Article 43, §556, Annotated Code of Maryland. “Section 556 related institutions” or “related institutions” means all related institutions as defined in Article 43, §556, Annotated Code of Maryland. “Trustee" or "director” means any person serving on a governing board or committee of a nonprofit hospital or related institution who is empowered to vote on matters concerning the hospital's or related institution's governance or other matters generally concerning its policies. “Willfully” means acting in a purposeful and not a negligent or accidental manner, but need not encompass a criminal intent not to observe or to breach any statute or rule of law. The Accounting System. The accounting system set forth in the Commission's "Accounting and Reporting System for Hospitals” first issued in February, 1973, shall be used by all hospitals under the jurisdiction of the Commission for their fiscal year period beginning on or after April 1, 1973, and all subsequent periods. The “Accounting and Reporting Systems for Hospitals”, also known as the Accounting and Budget Manual for Fiscal and Operating Management (October 1, 2024) is incorporated by reference. The Commission shall provide each hospital under its jurisdiction with a copy of the most recently updated Accounting and Budget Manual for Fiscal and Operating Management, which shall represent the official interpretation of accounting and reporting practices and procedures of the System. The Executive Director is authorized and empowered by the Commission to allocate specific items to specific accounts within the system when the allocations are necessary to assume uniformity of accounting procedures. Furthermore, any proposed technical changes to the Accounting and Budget Manual will be posted on the HSCRC website for public comment. Technical changes mean non-substantive, revenue neutral updates. Requests for exceptions to the system may be filed as provided in §C. Accrual Accounting. A full accrual basis of accounting for revenue and expenses is required. Revenues shall be given recognition in the period during which the service is provided. Revenue shall be recorded at the full established rates regardless of the amounts actually paid to the hospital or on behalf of the patients. Revenue deductions shall be given accounting recognition in the same period that the related revenues are recorded. Expenses shall be given recognition in the period in which there is: A direct identification or association with revenue, as in the case of services rendered to patients; An indirect association with revenue, as in the case of salaries or rent; or A measurable expiration of asset costs even though not associated with the production of revenue for the current period as in the loss from fire. Requests for Exceptions to System Manual. As provided by Health-General Article, §19-211(b), hospitals may file a written request for exception with the Commission. The Executive Director shall respond in writing promptly to the requesting hospital on receipt of the request acknowledging its receipt and providing the requesting hospital with a date by which the request shall be answered. If needed for evaluation of the request, the Executive Director will seek additional information from the appropriate source. Review of Denial of Request for Exception. Any hospital denied an exception to the accounting system or manual may file a written petition to the Commission for a hearing to review the action of the Executive Director in refusing its request for exception. A petition for a hearing to review the Executive Director's action shall be filed with the Commission within 15 days of the date on which the aggrieved hospital was notified in writing of the action taken on the requested exception, and shall state the grounds for the petition. A hearing on the petition, at which the petitioner may be represented by counsel, shall be held within 30 days of the date on which the petition was filed, before a review subcommittee composed of three members of the Commissioners chosen by the Chairman for that purpose. The review subcommittee shall consist of at least two persons who have no connection with the management or policy of any hospitals or related institutions. Promptly after the hearing, the subcommittee shall report to the Commission, which shall make its decision within 45 days of the submission of the petition to review. The decision of a majority of the Commission, which shall be recorded in the form of a written decision filed with the Commission's office, shall be final, subject to the right of appeal in accordance with Health-General Article, §19-221. Annual Financial Statements. The following audited financial statements are required to be submitted by each Section 556 hospital, with the exception of those hospitals that are a part of the Maryland Department of Health: Balance Sheet—Unrestricted Funds (AUB); Balance Sheet—Restricted Funds (ARB); Statement of Change in Equity (AFB); Statement of Revenue and Expense (ARE); Statement of Change in Financial Position (AFP). The above reports shall be recorded on the basis of actual data and be submitted within 90 days after the end of each hospital's fiscal year. Report AUB, ARB, AFB, ARE, and AFP as required above shall include attests by the institution's certified public accountants. Monthly Financial Statements. The following unaudited financial statements are required to be submitted by each Section 556 hospital, with the exception of those hospitals that are a part of the Maryland Department of Health: Balance Sheet—Unrestricted Funds (QUB); Balance Sheet—Restricted Funds (QRB); Statement of Revenues and Expenses (QRE). The above reports shall be recorded on the basis of actual data and be submitted within 30 days after the end of each month of the calendar year. Monthly Financial Statement Summary. The following unaudited monthly financial statement summary is required to be submitted by each Section 556 hospital, with the exception of those hospitals that are a part of the Maryland Department of Health: Financial Statement Summary—(FS). Schedule FS shall be completed on the basis of actual data in the form prescribed by the Commission contained in the “Accounting and Reporting System for Hospitals”. Schedule FS is to be submitted within 30 days after the end of each month of the calendar year in the format prescribed by the Commission. Monthly Reports of Achieved Volumes and Revenues. The following monthly volume and revenue reports are required to be submitted by each hospital under the jurisdiction of the Commission, with the exception of those hospitals that are a part of the Maryland Department of Health: Statistical Data and Revenue Summary — Daily Hospital Services; Statistical Data and Revenue Summary — Ambulatory Services and Admissions Services; Statistical Data and Revenue Summary — Ancillary Services. The Monthly Reports of Achieved Volumes and Revenues shall be completed on the basis of actual data in the format prescribed by the Commission. The Monthly Reports of Achieved Volumes and Revenues shall be submitted within 30 days after the end of each month of the calendar year in the format prescribed by the Commission. The Monthly Reports of Achieved Volumes and Revenues submitted under this section shall be made in the format as published in the Maryland Register and on the Commission’s website (http://www.hscrc.maryland.gov). Annual Report of Revenue and Volume Comparisons. The following annual report of revenue and volume comparisons is required to be submitted by each Section 556 hospital, with the exception of those hospitals that are a part of the Maryland Department of Health: Revenue and Volume Comparisons (RVC). Schedule RVC shall be completed on the basis of actual data in the form prescribed by the Commission contained in the “Accounting and Reporting System for Hospitals”. Schedule RVC shall be submitted within 90 days after the end of each hospital's fiscal year in the format prescribed by the Commission. Annual Reports of Revenues, Expenses, and Volumes. The following annual reports of revenues, expenses, and volumes are required to be submitted by each Section 556 hospital, with the exception of those hospitals that are a part of the Maryland Department of Health: Inpatient and Patient Days (V1A, V1B, V1C, V1D); Outpatient Visits (V2A, V2B); Ancillary Service Units (V3A, V3D); Equivalent Inpatient Days and Admissions (V5); Allocation of Data Processing (DP1); Unassigned Expense (UA); Hospital Based Physicians (P1A, P1B); Medical Staff Services (P2A to P2I); Physical Support Services (P3A to P3H); Residents, Interns Services—Eligible (P4A to P4I); Residents, Interns Services—Ineligible (P5A to P5I); Overhead Expense Summary (OES); General Service Center (C1 to C14); Patient Care Center (D1 to D81); Auxiliary Enterprises (E1 to E9); Other Institutional Programs (F1 to F4); Allocation of Cafeteria, Parking, Etc. (OAA to OAK); Reconciliation of Base Year Expenses to Schedule RE (RC); Statement of Revenue and Expenses (RE); Overhead Expense Apportionment (J1 to J4); Overhead Statistical Apportionment (J51 to J54); Building Facility Allowance (H1); Departmental Equipment Allowance (H2A to H2Y); Distribution of Capital Facilities Allowances (H3A to H3D); Capital Facility Allowance Summary (H4); Cash and Marketable Assets (GR); Payor Differential (PDA); MB Revenue (M, MA, MB); Unregulated Services (UR1 to UR6); Operating Room Survey (ORS); Other Financial Considerations (G); Annual Cost Survey (ACS); Transactions with Related Entities (TRE); Revenue and Volume Comparisons (RVC); Schedule D Personnel Schedules (PH1 to PH2); Utilization of Therapies (TU). Mandated Trauma Cost (MTC); and Stand-By Costs (SBC). The above annual reports of revenues, expenses, and volumes shall be completed on the basis of actual data and certain projected data in the form prescribed by the Commission in the “Accounting and Reporting System for Hospitals”. The above annual reports of revenues, expenses, and volumes shall be submitted within 90 days after the end of each hospital's fiscal year in the format prescribed by the Commission. Collection and Submission of Data. Upon the effective date of this regulation, each hospital under the jurisdiction of the Health Services Cost Review Commission shall submit the following data elements relative to bad debts and uncompensated care in accordance with the instructions detailed in the Accounting and Budget Manual: Inpatient uncompensated care and bad debts; Outpatient uncompensated care and bad debts. Repealed. Special Audit. An audit of various data submitted in the Annual Reports of Revenues, Expenses, and Volumes, Wage and Salary Survey, and the Annual Report of Change in Building and Equipment Fund Balances is required to be performed by the independent certified public accounting firm of each Section 556 hospital, with the exception of those hospitals that are a part of the Maryland Department of Health. The audit procedures shall be completed in the form prescribed by the Commission contained in the “Accounting and Reporting System for Hospitals”. The results of the audit shall be submitted to the Commission within 110 days after the end of each hospital's fiscal year in the format prescribed by the Commission. Annual Reports of Wage and Salary Survey. The following annual reports of wage and salary survey are required to be submitted by each Section 556 hospital, with the exception of those hospitals that are a part of the Maryland Department of Health: Wage, Salary and Fringe Benefits Summary (WSA, WSB, WSC); Fringe Benefits Calculation (FB). Schedules WSA, WSB, WSC, and FB shall be completed on the basis of actual data in the form prescribed by the Commission contained in the “Accounting and Reporting System for Hospitals”. Schedules WSA, WSB, WSC, and FB shall be submitted by June 1 of every calendar year in the format prescribed by the Commission. The Commission may require the submission of nonpersonally identifiable wage and salary data elements for individual employees. Rate Review Reports. The following rate review reporting schedules are required to be submitted by each Section 556 hospital, with the exception of those hospitals that are a part of the Maryland Department of Health: Inpatient and Patient Days (V1A, V1B, V1C, V1D); Outpatient Visits (V2A, V2B); Ancillary Service Units (V3A, V3D); Equivalent Inpatient Days and Admissions (V5); Allocation of Data Processing (DP1); Unassigned Expense (UA); Hospital Based Physicians (P1A, P1B); Medical Staff Services (P2A to P2I); Physician Support Services (P3A to P3H); Residents, Interns Services—Eligible (P4A to P4I); Residents, Interns Services—Ineligible (P5A to P5I); Overhead Expense Summary (OES); General Service Center (C1 to C14); Patient Care Center (D1 to D81); Auxiliary Enterprises (E1 to E9); Other Institutional Programs (F1 to F4); Allocation of Cafeteria, Parking, etc. (OAA to OAK); Reconciliation of Base Year Expenses to Schedule RE (RC); Statement of Revenue and Expenses (RE); Overhead Expense Apportionment (J1 to J4); Overhead Statistical Apportionment (J51 to J54); Building Facility Allowance (H1); Departmental Equipment Allowance (H2A to H2Y); Distribution of Capital Facilities Allowances (H3A to H3D); Capital Facility Allowance Summary (H4); Cash and Marketable Assets (GR); Payor Differential (PDA); MB Revenue Centers (M, MA, MB); Unregulated Services (UR1 to UR6); Operating Room Survey (ORS); Other Financial Considerations (G); Annual Cost Survey (ACS); Transactions with Related Entities (TRE); Revenue and Volume Comparisons (RVC); Schedules D Personnel Schedules (PH1 to PH2); Utilization of Therapies (TU); (MTC) Mandated Trauma Cost; and (SBC) Stand-by Costs. The above review reports shall be completed on the basis of actual data and certain projected data in the form prescribed by the Commission in the “Accounting and Reporting System for Hospitals”. Interns and Residents Survey. Hospitals shall submit the Interns and Residents Survey to the Commission by January 15 of every calendar year. Hospitals shall complete the survey on the basis of actual data in the form prescribed by the Commission. General Assembly Studies and Other Reports. The Commission may require hospitals to submit information in response to information required of the Commission by the Maryland General Assembly. Annual Nonprofit Hospital Community Benefit Report. Beginning on December 15, 2009, each nonprofit hospital shall submit the Annual Nonprofit Hospital Community Benefit Report to the Commission by the date prescribed by the Commission in the format prescribed by the Commission. Hospitals shall complete the report on the basis of actual data covering the reporting period of the previous July 1 through June 30 or other time period as specified by the Commission. The Commission shall provide instructions for completing the report on its public website. Internal Revenue Service Form 990. Beginning on October 1, 2009, each nonprofit hospital shall submit its most recent Form 990 that the facility filed with the Internal Revenue Service within 30 days from the Internal Revenue Service filing. Annual Debt Collection Report. Hospitals shall submit the Annual Debt Collection Report to the Commission within 60 days after the end of each hospital’s fiscal year. Hospitals shall complete the report on the basis of actual data in the form prescribed by the Commission. The Commission shall provide instructions for completing the report in its Accounting and Budget Manual for Fiscal and Operating Management. All-Payer Model Agreement Data Requirements. Hospitals shall submit data in accordance with the requirements of the January 1, 2014 All-Payer Model Agreement executed between the State of Maryland and the Center for Medicare and Medicaid Innovation for evaluation purposes. Report Format Changes. The Commission, after consideration at a public meeting or other public forum, may modify the reporting requirements of the above reports as it deems necessary, if reasonable notice is given to each hospital under its jurisdiction and all designated interested parties using the “Accounting and Reporting System for Hospitals”. Failure to File Reports. A hospital under the jurisdiction of the Commission which does not file any report under the Enabling Act of the Commission, Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland, or under the regulations of the Commission, is liable for a civil penalty of up to $1,000 per day for each day the filing of the report is delayed unless an extension is granted as provided in §O of this regulation. These fines may not be considered reasonable costs for purposes of rate setting by the Commission. The Commission may refuse to grant a rate increase to any hospital which does not file a report required under its enabling legislation (Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland) or its regulations. Any required report submitted to the Commission which is substantially incomplete or inaccurate may not be considered timely filed. In addition, any incomplete or inaccurate report submitted by a hospital that results in, or will result in, rates which, through the application of normal Commission methodology, vary, or will vary, from the allowed corridors specified in COMAR 10.37.03.05F, may not be considered timely filed. All annual reports required to be filed with the Commission shall contain an attestation by the institution's chief financial officer that, to the best of the officer's information and belief, the reports filed have been prepared in conformity with the Commission's uniform accounting and financial reporting system as set forth in the Manual. All annual reports required to be filed with the Commission shall contain an attestation by the institution's chief executive officer that, to the best of the officer's information and belief, neither the hospital, its related entity, nor any entity or person acting on behalf of or in concert with the hospital knowingly is participating in or receiving the benefit of any fixed price arrangement, directly or indirectly, pertaining to the delivery of hospital services without approval by the Commission. Requests for Extension of Time to File Required Reports. A Section 556 hospital under the jurisdiction of the Commission may file with the Commission written requests for reasonable extensions of time to file any or all of the required reports. The requests for extensions will be supported by justification for the approval of the extension request. The Executive Director shall respond promptly in writing to the requesting hospital upon receipt of the request by either approving or disapproving the request. If it is needed for evaluation of the request, the Executive Director will seek information from the requesting hospital. Requests for extensions shall be made at a reasonable time before the due date of a required report. Extensions will be granted only for valid reasons. In the case of a submission of the Annual Reports of Revenues, Expenses, and Volumes, requests for extensions shall generally be made at least 45 days before the due date. Failure of a hospital to have its audited financial statements completed may generally not constitute a valid reason for an extension. Review of Denial of Request for Extension. A hospital denied an extension of time under §O may file a written petition with the Commission for a hearing to review the action of the Executive Director in refusing its request for extension. A petition for a hearing to review the Executive Director's action shall be filed with the Commission within 15 days of the date on which the aggrieved hospital was notified in writing of the action with respect to the requested extension and shall state the grounds for the petition. A hearing on the petition, at which the petitioner may be represented by counsel, shall be held within 30 days of the date on which the petition was filed, before a review subcommittee composed of three members of the Commission chosen by the Chairman for that purpose. The review subcommittee shall consist of at least two persons who have no connection with the management or policy of any hospitals or related institutions. Promptly after the hearing, the subcommittee shall report to the Commission which shall make its decision within 45 days of the submission of the petition to review. The decision of a majority of the Commission, which shall be rendered in the form of a written decision filed in the Commission's office, shall be final, subject to the right of review in accordance with Health-General Article, §19-221. Stay of Charges. Unless the Commission reverses the Executive Director, the filing of a written petition pursuant to §P may not stay the continued accrual of the charges levied under §N against a hospital which fails to meet the deadline for filing reports required in these regulations. If the Commission affirms the decision of the Executive Director, the penalties which accrued during the appeal period may be suspended or reduced by the Commission. The Accounting System. The accounting system set forth in the Commission's “Accounting and Reporting System for Related Institutions” issued in March, 1973, shall be used by all Section 556 related institutions for their fiscal year period beginning on, or after, April 1, 1973, and all subsequent periods. The “Accounting and Reporting System for Related Institutions” is incorporated in these regulations as if set forth in full. The Commission shall provide each section 556 related institution with a copy of “Accounting and Reporting System for Related Institutions” which may be amended pursuant to the Administrative Procedure Act, State Government Article, Title 10, Annotated Code of Maryland. The Executive Director is authorized and empowered by the Commission to allocate specific items to specific accounts within the System when the allocations are necessary to assure uniformity of accounting procedures. Requests for exceptions to the System may be filed as provided in §D, of this regulation. Accrual Accounting. A full accrual basis of accounting for revenue and expenses is required. Revenues shall be given recognition in the period during which the service is provided. Revenues shall be recorded at the full established rates regardless of the amounts actually paid to the related institution by, or on behalf of, the patients. Revenue deductions shall be given accounting recognition in the same period that the related revenues are recorded. Expenses shall be given recognition in the period in which there is: A direct identification or association with revenue, as in the case of services rendered to patients; An indirect association with revenue, as in the case of salaries or rent; or A measurable expiration of asset costs even though not associated with the production of revenue for the current period, as in the case of losses from fire. Manual. As may be necessary to assure uniformity of accounting and reporting procedures, the Commission may adopt a manual which will be supplemental to the system hereby adopted, to be incorporated in these regulations in the same manner as set forth in §A(2), of this regulation. The Commission shall provide each section 556 related institution with a copy of the manual, which may be amended pursuant to the Administrative Procedure Act, State Government Article, Title 10, Annotated Code of Maryland. Any manual adopted by the Commission shall be the official interpretation of accounting and reporting practices and procedures within the Related Institution Accounting and Reporting System. Requests for exceptions to the manual may be filed as provided in §D, of this regulation. Requests for Exceptions to System or Manual. As provided by Health-General Article, §19-211(b), Annotated Code of Maryland, related institutions may file a written request for exception with the Commission. The Executive Director shall respond in writing promptly to the requesting related institution on receipt of the request, acknowledging its receipt and providing the requesting related institution with a date by which the request shall be answered. If needed for evaluation of the request, the Executive Director will seek additional information from the appropriate source. Review of Denial of Request for Exception. Any related institution denied an exception to the accounting system or manual may file a written petition to the Commission for a hearing to review the action of the Executive Director in refusing its request for exception. A petition for a hearing to review the Executive Director's action shall be filed with the Commission within 15 days of the date on which the related institution aggrieved was notified in writing of the action taken on the requested exception and shall state the grounds for the petition. A hearing on the petition, at which the petitioner may be represented by counsel, shall be held within 30 days of the date on which the petition was filed, before a review subcommittee composed of three members of the Commission chosen by the Chairman for that purpose. The review subcommittee shall consist of at least two persons who have no connection with the management or policy of any hospitals or related institutions. Promptly after the hearing, the subcommittee shall report to the Commission which shall make its decision within 45 days of the submission of the petition to review. The decision of a majority of the Commission, which shall be rendered in the form of a written decision filed in the Commission's office, shall be final, subject to the right of appeal in accordance with Health-General Article, §19-221, Annotated Code of Maryland. Required Annual Reports and Statements. Each section 556 related institution shall submit annually to the Commission, within 90 days after the close of the related institution's annual accounting period (fiscal year), the following reports and statements as specified in Section III of Accounting and Reporting System for Related Institutions: A balance sheet (Schedule D); A statistical, cost finding and revenue analysis report (Schedules A, B, and G); A profit and loss statement (Schedule C); Statements of selected data related to owners and related organizations (Schedules E and F); Certification (Schedule H); A statement of its dealings and relationships with certain entities. Report Formats. The required report and statement formats to be used by section 556 related institutions when submitting the annual reports and statements required by §A, of this regulation, are those presented in the Commission's “Accounting and Reporting System for Related Institutions,” except for the statement required under §A(6), of this regulation. Nonprofit related institutions shall file a verified statement pursuant to §A(6), of this regulation, setting forth the following information in substantially the following form: Proprietary related institutions shall file a verified statement pursuant to §A(6) setting forth the following information in substantially the following form: Failure to File Reports. Any section 556 related institution which does not file any report or statement required herein is liable for a civil penalty of $100 per day for each day the filing of the report or statement is delayed unless an extension is granted as provided in §D of this regulation. This penalty may not be considered a part of reasonable costs for purposes of rate setting by the Commission. Requests for Extension of Time to File Required Reports or Statements. Any section 556 related institution may file with the Commission written requests for reasonable extensions of time to file any or all of the required reports or statements. The requests for extensions shall be supported by justification for the approval of the extension requests. The Executive Director shall respond promptly in writing to the requesting related institution upon receipt of the requests by either approving or disapproving the requests. If needed for evaluation of any request, the Executive Director will seek additional information from the requesting related institution. Review of Denial of Request for Extension. Any related institution denied an extension of time under §D may file a written petition with the Commission for a hearing to review the action of the Executive Director in refusing its request for extension. A petition for a hearing to review the Executive Director's action shall be filed with the Commission within 15 days of the date on which the related institution aggrieved was notified in writing of the action with respect to the requested extension and shall state the grounds for the petition. A hearing on the petition, at which the petitioner may be represented by counsel, shall be held within 30 days of the date on which the petition was filed, before a review subcommittee composed of three members of the Commission chosen by the Chairman for this purpose. The review subcommittee shall consist of at least two persons who have no connection with the management or policy of any hospital or related institution. Promptly after the hearing, the subcommittee shall report to the Commission, which shall make its decision within 45 days after the date of the submission of the petition to review. The decision of a majority of the Commission, which shall be rendered in the form of a written decision filed in the Commission's office, shall be final, subject to the right of review in accordance with Health-General Article, §19-221, Annotated Code of Maryland. Stay of Charges. Unless the Commission reverses the action of the Executive Director, the filing of a petition pursuant to §E may stay the continued accrual of the charges levied under §C against a related institution which fails to meet the deadline for filing reports or statements required in these regulations. In cases where the Commission affirms the action of the Executive Director, the penalties which accrued during the appeal may be suspended or reduced by the Commission. The Guide and Instructions. The Guide for the Trustee's Disclosure of Interest Statement and the instructions for it set forth immediately following these regulations concerning disclosure, are hereby incorporated in these regulations. Periods Covered by the Statement. The statement shall report all business transactions described in Health-General Article, §19-220, Annotated Code of Maryland, during the hospital's or related institution's fiscal year beginning on, or after, July 1, 1973 and an additional statement shall report business transactions during each succeeding fiscal year of the hospital or related institutions or fraction of that year that the trustee serves the hospital or related institution. Filing of Statements. The trustee shall file the completed, executed, and verified statement with the Commission within 90 days after the end of the fiscal year to which it applies. Failure or Delay in Filing Statements. Any trustee who does not file the statement on the date it is due is liable for a civil penalty or fine of $250 per day for each day the filing of the statement is delayed, unless an extension is granted and a stay of filing is granted as provided in §§E, F, and G of this regulation. This penalty or fine may not be considered reasonable costs for purposes of rate setting by the Commission if the hospital or related institution reimburses or indemnifies the trustee therefor in any manner. Request for Extension of Time to File Statements. A trustee may file with the Commission a written request for a reasonable extension of time to file his statement. The request for extension shall be supported by justification for the approval of the extension request. The Executive Director shall respond promptly in writing to the requesting trustee upon receipt of the request by either approving or disapproving the request. If needed for evaluation of the request, the Executive Director may seek additional information from the requesting trustee, his firm, the hospital or related institution on whose board he serves, or other pertinent sources. Review of Denial of Request for Extension. Any trustee denied or given an inadequate extension of time under §E, of this regulation, may file a written petition with the Commission to review the action of the Executive Director in refusing his request for extension or giving him an inadequate extension, within 10 days of the date on which the trustee was notified in writing of the action with respect to the requested extension. The petition shall state the grounds for the proposed extension and request a review of the denial of his request for it. A hearing on the petition, at which the petitioner may be represented by counsel, shall be held within 20 days of the date on which the petition was filed, before a disclosure subcommittee composed of one or more members of the Commission chosen by the Chairman for that purpose. The disclosure subcommittee shall consist of a majority of persons who have no connection with the management of policy of any hospital or related institution. Promptly after the hearing, the disclosure subcommittee shall report to the Commission which shall render its decision within 30 days of the submission of the petition to review. The decision of a majority of the Commission, which shall be rendered in the form of a written decision filed in the Commission's office, shall assess a specific penalty not exceeding the amount of penalty set forth in §D, of this regulation, or state that no penalty is imposed, as set forth in these regulations, and shall be final, subject to the right of review in accordance with Health-General Article, §19-221, Annotated Code of Maryland. Accrual of Penalty. The filing of a petition pursuant to §F, of this regulation, may not stay the accrual of the penalty imposed pursuant to §D, of this regulation. However, the penalty may not be assessed against or collected from the trustee until the conclusion of the proceeding initiated by the trustee's petition. The penalty may be modified in accordance with the Commission's decision, and the Commission may abate or reduce the penalty as justice and equity may require. Review, Question, and Substantiation of the Statement. During the 6 months immediately following the filing of each statement, the Commission, after a review of it, may question the statement and require substantiation of facts and matters set forth in it. During the 3 years immediately following the filing of each statement, the Commission, after a review of it, may question the statement as to any relevant fact or matter not set forth in it and require explanations and other disclosures regarding these facts and matters. During the 4 years immediately following the end of each fiscal year of a hospital or related institution, the Commission may question the business transactions between the hospital or related institution and any firm connected as set forth in these regulations with any of the hospital's or related institution's trustees who did not file a statement pertaining to that year. Upon any question by the Commission as set forth in this regulation, the Commission's staff may investigate the questioned situation and hold informal conferences with the trustee in question, or other persons having knowledge of the situation, and hearings may be held on it by the Commission or a subcommittee of the Commission. At informal conferences of the questioned trustee or other persons with the Commission staff, the attendance of persons and the production of specific records, documents, contracts, data, checks, ledgers, or other papers of the trustee, his firm, or the hospital or related institution may be requested, and the Executive Director or his designee may administer oaths or affirmations in the course of statements by any person and in the course of proffers of documents or other papers by the trustee or any person. At hearings held as a result of any questions regarding a trustee's disclosure or lack of disclosure, as set forth in this regulation, the Commission may subpoena witnesses, papers, records, and documents relating to it in the possession of any person, entity, or hospital or related institution. At any time before or during an informal conference held under these regulations, the questioned trustee, if he is scheduled to appear or is present at the conference, or the senior member of the Commission's staff participating in the conference, may request a hearing thereon before the Commission or a subcommittee of the Commission, and this informal conference shall be cancelled or terminated, as the case may be, and a hearing promptly scheduled. Statements, facts, or matters fully set forth in it may not be questioned after 6 months after its filing, and unless the particular trustee is notified in writing of the question by the Commission during the 6-month period, all investigations of it shall cease. However, all questions, investigations, and other actions begun during the 6 month period or which are the subject of notice to the trustee as set forth in this regulation, shall be continued to a proper conclusion. Information Required of Non-Profit Facilities. A nonprofit facility subject to the jurisdiction of the Commission shall file with the Commission within 90 days from the close of its fiscal year a list of all trustees, directors, or officers of the facility. The list shall include the following: The name and business address of the trustee, director, or officer; and For each person so named, the nonprofit facility shall indicate whether the trustee, director, or officer is also an employee, partner, director, or beneficial owner of 3 percent or more of the capital account or stock of a partnership, firm, corporation, or any other business entity. The information referred to in §I(2)(b), of this regulation, shall only be required if the business entity engaged in a transaction of $10,000 or more with the nonprofit facility during the previous fiscal year. In order for the Commission to be able to assure the public that the costs of a hospital are reasonable and that the reports submitted by a hospital are accurate, the Commission may, at any time, conduct an investigation of a hospital's relevant records and accounts. General. A facility subject to the jurisdiction of the Commission shall notify the Commission, in writing, within 30 days before executing any financial transaction, contract, or other agreement that would: Pledge more than 50 percent of the operating assets of the facility as collateral for a loan or other obligation; Result in more than 50 percent of the operating assets of the facility being sold, leased, or transferred to another person or entity; or Result in more than 50 percent of all corporate voting rights or governance reserve powers being transferred to or assumed by another person or entity. Information Required. A facility shall file with the Commission within 30 days before executing a proposed financial transaction, contract, or other agreement as required in §A of this regulation, the following information: The name and address of the person or entity to whom: The operating assets of the facility are being sold, leased, transferred, or pledged as collateral for a loan or other obligation; or The corporate voting rights or governance reserve powers are being transferred or assumed. The precise nature of the financial transaction, contract, or other agreement. Failure or Delay in Reporting Certain Financial Transactions. A facility under the jurisdiction of the Commission which does not notify the Commission of a proposed financial transaction, contract, or other agreement as required in §A of this regulation, is subject to all penalties prescribed by Commission law and regulation on failure to comply with reporting requirements. A required statement submitted to the Commission that is substantially incomplete or inaccurate is not considered timely filed. Publication of Notice by Commission. The Commission shall publish a notice of the proposed financial transaction, contract, or other agreement reported by a facility, in accordance with §A of this regulation, in a newspaper of general circulation in the area where the facility is located. Exception. The provisions of this regulation do not apply to any financial transaction, contract, or other agreement made by a facility with any issuer of tax-exempt bonds, including the Maryland Health and Higher Education Facilities Authority, the State, or any county or municipal corporation of the State, if a notice of the proposed issuance of revenue bonds that meets the requirements of §147(F) of the Internal Revenue Code has been published. Health-General Article, §§19-207, 19-215, and 19-303,Annotated Code of Maryland Effective date: April 24, 1973 Regulation .01B, C, E, F, J, and K adopted effective September 19, 1974 (1:1 Md. R. 17) Regulation .03 amended effective July 28, 1978 (5:15 Md. R. 1189) Regulation .03A, C amended effective May 4, 1979 (6:9 Md. R. 728) Regulation .03D amended effective October 29, 1975 (2:24 Md. R. 1481); May 11, 1977 (4:10 Md. R. 767) Regulation .03D, E amended effective April 7, 1978 (5:7 Md. R. 522) Regulation .03H amended effective August 18, 1976 (3:17 Md. R. 915); August 31, 1977 (4:18 Md. R. 1398); July 28, 1978 (5:15 Md. R. 1189); December 29, 1978 (5:26 Md. R. 1922); May 4, 1979 (6:9 Md. R. 728) Regulation .03I adopted effective August 18, 1976 (3:17 Md. R. 915) Regulation .03J adopted effective July 28, 1978 (5:15 Md. R. 1189); December 29, 1978 (5:26 Md. R. 1922); May 4, 1979 (6:9 Md. R. 728) Regulations .04 and .05 effective April 29, 1973 Regulation .05G amended as an emergency provision effective December 23, 1976 (4:2 Md. R. 73) Regulation .06 adopted effective September 19, 1974 (1:1 Md. R. 17) Regulation .07 adopted effective April 7, 1978 (5:7 Md. R. 522) Regulations .01—.03 amended effective October 3, 1980 (7:20 Md. R. 1879) Regulation .01A amended effective December 14, 1987 (14:25 Md. R. 2660) Regulation .02 amended effective December 14, 1987 (14:25 Md. R. 2660); May 29, 1989 (16:10 Md. R. 1109); April 5, 1999 (26:7 Md. R. 543) Regulation .02A amended effective January 8, 1990 (16:26 Md. R. 2793); February 4, 1991 (18:2 Md. R. 149); January 6, 1992 (18:26 Md. R. 2830); August 30, 1993 (20:17 Md. R. 1346); January 2, 1995 (21:26 Md. R. 2188); May 6, 1996 (23:7 Md. R. 553); April 7, 1997 (24:7 Md. R. 553); May 4, 1998 (25:9 Md. R. 680); April 5, 1999 (26:7 Md. R. 543); March 6, 2000 (27:4 Md. R. 454); July 9, 2001 (28:13 Md. R. 1216); September 30, 2002 (29:19 Md. R. 1524); March 29, 2004 (31:6 Md. R. 509); August 1, 2005 (32:15 Md. R. 1321); April 10, 2006 (33:7 Md. R. 673); June 4, 2007 (34:11 Md. R. 971); May 18, 2009 (36:10 Md. R. 717); April 5, 2010 (37:7 Md. R. 571); June 27, 2011 (38:13 Md. R. 756); July 9, 2012 (39:13 Md. R. 785); April 14, 2014 (41:7 Md. R. 422); December 21, 2015 (42:25 Md. R. 1543); August 13, 2018 (45:16 Md. R. 775); March 9, 2020 (47:5 Md. R. 311); February 8, 2021 (48:3 Md. R. 94); December 11, 2023 (50:24 Md. R. 1042); November 25, 2024 (51:23 Md. R. 1036); April 14, 2025 (52:7 Md. R. 323) Regulation .03 amended effective July 1, 1985 (12:13 Md. R. 1279); December 10, 2001 (28:24 Md. R. 2128); October 5, 2009 (36:20 Md. R. 1529) Regulation .03 amended as an emergency provision effective January 1, 2014 (41:2 Md. R. 89); amended permanently effective April 14, 2014 (41:7 Md. R. 422) Regulation .03 amended effective August 4, 2014 (41:15 Md. R. 890) Regulation .03D, E amended effective November 30, 2009 (36:24 Md. R. 1858) Regulation .03F repealed effective January 1, 1983 (9:16 Md. R. 1605) Regulation .03H amended effective January 1, 1984 (10:15 Md. R. 1351); October 10, 1994 (21:20 Md. R. 1732); February 12, 2007 (34:3 Md. R. 299) Regulation .03H, L amended effective August 3, 1981 (8:15 Md. R. 1308); November 19, 1984 (11:23 Md. R. 1992); July 1, 1985 (12:13 Md. R. 1279); March 10, 1986 (13:5 Md. R. 545) Regulation .03H, L amended as an emergency provision effective May 25, 1986 (13:12 Md. R. 1372); emergency status expired September 16, 1986 Regulation .03H, L amended effective November 3, 1986 (13:22 Md. R. 2399); December 15, 1986 (13:25 Md. R. 2660); December 28, 1987 (14:26 Md. R. 2747); September 4, 1989 (16:17 Md. R. 1886); April 27, 1992 (19:8 Md. R. 805) Regulation .03I repealed effective February 13, 2006 (33:3 Md. R. 241) Regulation .03K amended as an emergency provision effective April 1, 2003 (30:8 Md. R. 538); amended permanently effective July 7, 2003 (30:13 Md. R. 854) Regulation .03K amended effective June 6, 2005 (32:11 Md. R. 983) Regulation .03L amended effective February 13, 2006 (33:3 Md. R. 241) Regulation .03L-1, L-2 adopted effective March 8, 1999 (26:5 Md. R. 391) Regulation .03L-1 amended effective November 15, 2010 (37:23 Md. R. 1610) Regulation .03L-3 adopted effective June 9, 2003 (30:11 Md. R. 735) Regulation .03L-5 adopted effective January 13, 2011 (38:1 Md. R. 11) Regulation .03M amended effective November 11, 2024 (51:22 Md. R. 963) Regulation .03N amended as an emergency provision effective September 2, 1991 (18:19 Md. R. 2095); emergency status expired February 3, 1992 Regulation .03N amended effective January 6, 1992 (18:26 Md. R. 2830); March 8, 1999 (26:5 Md. R. 391); March 4, 2013 (40:4 Md. R. 346) Regulation .06D amended effective March 4, 2013 (40:4 Md. R. 346) Regulation .06I adopted effective June 30, 1986 (13:13 Md. R. 1492) Regulation .06I amended effective August 13, 2007 (34:16 Md. R. 1432) Regulation .08 adopted effective January 6, 1992 (18:26 Md. R. 2830) Regulation .08A, B amended effective September 14, 2015 (42:18 Md. R. 1174) The following terms have the meanings indicated. Terms Defined. “Consolidation” means the extinguishment of two or more hospitals and by the same process a new hospital organization is formed, taking over the assets and assuming the liabilities of those passing out of existence. “Mergers” means the union of two or more hospitals by the transfer of all the property of one or more of them to one of them, which continues in existence, the others being merged therein. Only the hospital that continues in existence will receive Commission approved rates for acute hospital services. Specific Standard. In the event of a merger or consolidation as a result of which one or more of the participating hospitals no longer provides inpatient care at its existing location, the Commission shall approve rates for the surviving hospital or hospitals such that the revenues of the surviving hospital or hospitals are increased based upon one of two variable cost calculations, with the merged or consolidated facility choosing between the options. The first alternative is for the surviving hospital or hospitals to receive in relation to the new admission variable costs in the first year equal to 80 percent. This figure shall be reduced to 70 percent in the second year for those new admissions. For the third year and after that, the variable cost amount built into the hospital's base for these admissions shall be 60 percent. These variable cost percentages shall be limited to the number of admissions at the closed hospital. These amounts shall be applied to the average cost of hospitals in the screening group of the closed hospital (adjusted for wage differences as appropriate). The second alternative is for the surviving hospital to receive the normal 50 percent variable cost factor plus direct adjustments reflecting: The cost of debt transferred from the closed facility; A reasonable allowance for employees who are displaced by the merger or consolidation; A reasonable allowance for the retraining of employees; A reasonable allowance that permits the surviving institution to generate capital to convert a closed facility to an alternate health care use in conformance with the State Health Plan, which is incorporated by reference under COMAR 10.24.07; and A reasonable retention of a portion of the savings over a 3-year period. A merged or consolidated hospital may request rates from the Commission at any time consistent with Commission law and regulation. A review of the hospital's request shall be undertaken in accordance with the review and approval procedures developed by the Commission in carrying out its responsibilities under Health-General Article, §19-217. Those procedures shall establish reasonable rates based upon the premise that hospitals are to provide effective and efficient service. Health-General Article, §19-216, Annotated Code of Maryland Effective date: Regulation .02 adopted effective May 15, 1986 (13:9 Md. R. 1030) A hospital may not increase any existing rate or charge of any class or type or impose any new rate or charge of any class or type without the approval of the Commission, except for those changes specifically excepted by regulation or order of the Commission. A hospital may vary its unit rates within any 100 percent inpatient patient care center without prior Commission approval, if the variation does not change the average charge per unit of service as prescribed in the Commission's Rate Review System. A hospital may not vary its unit rates within any ancillary or ambulatory center without prior Commission approval if the Commission's Rate Review System prescribes a unit of service for that center. Any hospital may change without prior approval of the Commission its unit rate or rates in any auxiliary enterprise or other institutional program as these centers are defined in the Commission's Uniform Accounting and Reporting System and the Commission's Rate Review System. Any hospital may institute a rate for a new patient care service if the rate is less than $100 and does not change the average charge per unit of service for the patient care area in which the new patient care service is being provided. For purposes of this regulation, the following definitions apply: “Overcharge” means any charge for a hospital service under the jurisdiction of the Commission that is in excess of its approved rate. “Undercharge” means any charge for a hospital service under the jurisdiction of the Commission that is less than its approved rate. When any hospital overcharges by more than the allowed corridors, as defined in §G of this regulation, that overcharge shall be recovered in prospective rates at 140 percent plus appropriate interest factors. When any hospital overcharges less than the allowed corridor, as defined in §G of this regulation, that overcharge shall be reduced from prospectively approved rates at the actual amount of overcharge plus appropriate interest. When any hospital undercharges more than 2 percent in obstetrics, nursery, labor and delivery, clinic, emergency room, pediatrics, or intensive care units, that undercharge may not be recovered in prospective periods. When any hospital undercharges less than 2 percent in the patient service centers listed in §D of this regulation, that undercharge shall be added to prospectively approved rates at the actual amount of undercharges. When a hospital undercharges beyond the allowed corridors, as defined in this section, the amount of undercharge in excess of the corridors less 40 percent shall be added to prospectively approved rates. These allowed undercharge corridors are defined as follows: Patient care areas, when the unit of service is Admissions center ---------------------------------- 3 percent; Ancillary service areas and ambulatory service Overcharge Corridors and Pricing for Medical/Surgical Supplies and Drugs. The allowed overcharge corridors are defined as follows: Daily patient care areas, ambulatory Labor and delivery room -------------------------- 3 percent; Renal dialysis ----------------------------------- 5 percent; Ancillary service areas other than labor and There are no price corridors for medical/surgical supplies and drugs. Notwithstanding this regulation, if any hospital's net overcharges are more than 1 percent of the hospital's total approved revenue, that overcharge shall be recovered in prospective rates at 140 percent plus appropriate interest factors. In cases when a flagrant disregard of approved rates is found, the Commission may require direct repayment of overcharges and penalties to those patients who were overcharged. The Commission may assess penalties as described in this regulation, for rates approved effective July 1, 1978. Each hospital shall promptly submit a rate application to the Commission for a change in rates whenever the source of a hospital-based physician's or physician support personnel's compensation has been modified (for example, a hospital-based physician previously compensated by the hospital commences billing fee for service or CRNA's previously compensated by the hospital are replaced by physicians billing fee for service. Any rate application submitted under the requirements of §A, of this regulation, shall relate only to those changes in rates resulting from a modification in the source of a hospital-based physician's or physician support personnel's compensation. Failure to submit a rate application as required under §A, of this regulation, shall subject the hospital to overcharge/undercharge penalties, as specified in Regulation .05, of this chapter, as if those funds presently provided for in rates and obtaining to the source of a hospital-based physician's compensation had not originally been approved. Each hospital shall promptly submit a rate application to the Commission for a change in rates whenever an educational program conducted by the hospital has been modified (for example, the loss of a school of nursing program, the loss of resident/intern program, or a decrease in the number of students enrolled in the program). Any rate application submitted under the requirements of §A, of this regulation, shall relate only to those changes in rates resulting from a modification in an educational program conducted by a hospital. Failure to submit a rate application as required under §A, of this regulation, shall subject the hospital to the overcharge/undercharge penalties as specified in Regulation .05, of this chapter, as if those funds presently provided for in rates and obtaining to the hospital's educational program had not originally been approved. Any hospital which incurs or accrues costs as a result of professional medical services which are personally rendered for an individual patient by a physician, and which contribute to the diagnosis or treatment of an individual patient, shall account for those costs as an Identified Physician Cost in accordance with the “Accounting and Reporting System for Hospitals” manual which is incorporated by reference in COMAR 10.37.01.02A(2). All those identified physician costs shall be charged to the individual patient as a separate charge and any bill rendered to a patient for those costs shall clearly and separately itemize those services and charges which are attributable to an identified physician cost. Any hospital may change without prior approval of the Commission its unit or rates for any identified physician cost as that center is defined in the Commission's “Accounting and Reporting System for Hospitals” and the Commission's “Rate Review System” which is incorporated by reference in COMAR 10.37.10.02B. The provisions of this regulation shall apply to all General Acute Care hospitals from October 1, 1983 and after that. A non-physician inpatient service is defined as a hospital service under the jurisdiction of the Commission provided by a third-party contractor to a hospital inpatient off-site of the hospital. The charge for this service shall be billed by the hospital. The allowable rate shall be equal to or less than the Statewide median or price standard as developed by staff. The same rate on average shall be charged to all inpatients, regardless of payor. The sum of the rate charged to a hospital inpatient and the professional component, if any, on average, shall be not greater than that charged on average by the third-party contractor to its other patients for the sum of both components of the same service. The hospital shall provide an audit by an independent CPA that the contractor is in compliance with Sec. D of this regulation. The hospital shall be at risk for any payment made to a contractor in excess of the allowable charge determined in accordance with Sec. B of this regulation. The Commission shall waive COMAR 10.37.10.07A, which requires a rate application be filed at least 60 days before the opening of a new service, for rate applications approved under this regulation. The sections of this regulation are nonseverable and the entire regulation shall be null and void 60 days after a Court of competent jurisdiction rules that any portion or section of this regulation is beyond the jurisdiction of the Commission. Generally. The Commission may, on its own or upon application from a hospital, permit charges for services to be changed without its prior approval in those cases when 66-2/3 percent or more of the annual gross patient revenue attributable to the services is derived from either Medicaid or Medicare patients, or both, who are not required by State law or by the terms of the Medicare Waiver to pay Commission-approved rates for those services. The Commission shall consider this action only in those instances when the annual gross revenue for nonphysician services is not more than $20 million (in 1996 dollars), adjusted by an appropriate index of inflation, or when the annual gross revenue subject to Commission rate-setting jurisdiction is not more than $5 million (in 1996 dollars) adjusted by an appropriate index of inflation. Filing of Application. A hospital seeking a rate-setting exemption under this regulation shall file a written application with the Commission identifying the service or services for which the exemption is requested. The application shall contain accurate and supporting documentation that the conditions set forth in §A of this regulation have been met for a minimum period of 12 months immediately before the application. The filing of an application for a rate-setting exemption does not constitute a contested case within the meaning of that term as defined in the Administrative Procedure Act. Review of Application. The Commission staff shall review the application within a reasonable period of time and prepare a written recommendation on the request to the Commission. The decision to grant or deny the application rests within the sound discretion of the Commission. Required Reports. A hospital granted an exemption under this regulation is required to file quarterly reports, in a manner to be prescribed by the Commission, in order to verify that the conditions set forth in §A of this regulation still obtain. The hospital shall continue to file all other required reports in conformity with the Commission's Accounting and Budget Manual for Fiscal and Operating Management (the Manual), which is incorporated by reference under COMAR 10.37.01.02. Attestation. Responsible officials of an applicant hospital are required to attest that, to the best of their knowledge and belief, the reports filed, as required under §D of this regulation, have been prepared in conformity with the Commission's uniform accounting and financial reporting system as set forth in the Manual. Further Investigation. If the Commission considers a further investigation necessary or desirable to authenticate information reported by a hospital seeking a rate-setting exemption, the Commission may make any further examination of the records or accounts of the hospital in accordance with the rules or regulations of the Commission. Termination of Exemption. The Commission may terminate an exemption granted under this regulation at any time for cause. Health-General Article, §§9-207, 19-210, 19-212, 19-215, 19-217, 19-219, and 19-220, Annotated Code of Maryland Effective date: June 14, 1975 (2:15 Md. R. 1066; 2:20 Md. R. 1298) Chapter revised effective August 18, 1976 (3:17 Md. R. 915) Regulation .02 amended effective October 6, 2008 (35:20 Md. R. 1775) Regulation .05 adopted effective July 28, 1978 (5:15 Md. R. 1189) Regulation .05 amended effective August 31, 1992 (19:17 Md. R. 1607) Regulation .05F amended effective April 15, 1991 (18:7 Md. R. 773) Regulation .05G amended effective January 2, 1993 (19:26 Md. R. 2288) Regulations .06 and .07 adopted effective August 3, 1981 (8:15 Md. R. 1308) Regulation .06A, B amended effective November 19, 1984 (11:23 Md. R. 1992) Regulation .08 adopted effective April 12, 1982 (9:7 Md. R. 711) Regulation .08 amended effective October 10, 1983 (10:20 Md. R. 1788) Regulation .09 adopted as an emergency provision effective April 1, 1984 (11:8 Md. R. 712); emergency status expired July 1, 1984; adopted permanently effective November 19, 1984 (11:23 Md. R. 1992) Regulation .09 amended effective February 9, 1987 (14:3 Md. R. 274) Regulation .09A amended effective July 9, 1990 (17:13 Md. R. 1611); December 8, 2005 (32:24 Md. R. 1905) Regulation .09B amended effective January 8, 1990 (16:26 Md. R. 2794); July 10, 2000 (27:13 Md. R. 1211); December 8, 2005 (32:24 Md. R. 1905) Regulation .10 adopted effective September 3, 1990 (17:17 Md. R. 2080) Regulation .10 amended effective August 5, 1991 (18:15 Md. R. 1727) Regulation .10A amended effective October 6, 1997 (24:20 Md. R. 1404) Effective January 1, 2014, each hospital under the jurisdiction of the Health Services Cost Review Commission (Commission) shall submit the data elements as published in the Maryland Register and on the Commission's website (http://www.hscrc.maryland.gov) to the Commission within 15 days following the last day of the month during which the patient was discharged or died. The format for submission shall also be as published in the Maryland Register and on the Commission's website. A hospital under the jurisdiction of the Commission may apply to the Commission for an exception or an extension to the filing requirements of §A of this regulation as provided for in COMAR 10.37.01.02 and .03. In this chapter, the following terms have the meanings indicated. Terms Defined. “Health Services Cost Review Commission (Commission)” means the independent organization within the Maryland Department of Health that is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, §19-201 et seq., Annotated Code of Maryland. “Hospital outpatient” means an encounter or visit to a hospital that does not result in an admission to the hospital. Data submitted to the Commission in accordance with this chapter are not public information pursuant to Health-General Article, §19-207, Annotated Code of Maryland. Summary studies, reports, or other compilations developed by the Commission or Commission staff from data submitted in accordance with this chapter shall be public information provided that, consistent with statutory law, disclosure is made in such a way that an individual patient or physician is not identified. The Commission shall prescribe the process for hospitals to submit corrections and revisions to the data on its website. Health-General Article, §§19-207, 19-212, 19-215, and 19-216, Annotated Code of Maryland Effective date: December 2, 1996 (23:24 Md. R. 1682) Regulation .02B amended effective November 13, 2000 (27:22 Md. R. 2060) Regulations .03 and .04 amended as an emergency provision effective July 1, 1998 (25:15 Md. R. 1182); amended permanently effective October 5, 1998 (25:20 Md. R. 1531) Regulation .03 amended effective September 3, 2001 (28:17 Md. R. 1556) Regulation .03B amended effective November 13, 2000 (27:22 Md. R. 2060; July 4, 2005 (32:12 Md. R. 1110) Regulation .04 amended effective November 13, 2000 (27:22 Md. R. 2060); September 3, 2001 (28:17 Md. R. 1556) Regulation .04G amended effective July 4, 2005 (32:12 Md. R. 1110) Regulations .01—.07 repealed effective June 4, 2007 (34:11 Md. R. 972) Regulations .01—.07 adopted effective June 4, 2007 (34:11 Md. R. 972) Chapter revised effective March 9, 2009 (36:5 Md. R. 422) Regulation .01A amended as an emergency provision effective January 1, 2014 (40:24 Md. R. 2014); amended permanently effective March 3, 2014 (41:4 Md. R. 301) Effective date: July 7, 1976 (3:14 Md. R. 750) Regulation .01 adopted effective July 6, 1977 (4:14 Md. R. 1082) Regulations .02 and .03 adopted effective July 15, 1979 (6:12 Md. R. 1050) Chapter repealed effective July 20, 1981 (8:14 Md. R. 1227) Beginning on January 1, 2014, each hospital under the jurisdiction of the Health Services Cost Review Commission shall submit to the Commission: The data elements required by this chapter within 15 days after the last day of the month when the patient was discharged or died; and The reconciliation of inpatient data between the discharge data and the financial data filed with the Commission. Submission Requirements. The data elements submitted under §A(1) o this regulation shall be made in the form as published in the Maryland Register and on the Commission’s website (http://hscrc.maryland.gov). The reconciliation submitted under §A(2) of this regulation shall be made in the manner, form, and time frame prescribed by Commission staff. A hospital may apply to the Commission for an exception or an extension to its filing requirements as provided in COMAR 10.37.01.02 and .03. Failure to submit the required data and reconciliation information in a timely manner may subject the hospital to monetary penalties as provided in Commission law and regulation. The requirements for the collection and submission of data as described in Regulation .01 of this chapter shall also apply to those non-federal acute care hospitals located in Delaware, Pennsylvania, Virginia, West Virginia, and the District of Columbia. Data submitted by these non-Maryland hospitals shall relate exclusively to those patients who are Maryland residents. The Commission may consider these non-Maryland hospitals that otherwise provide discharge data as described in Regulation .04 of this chapter to the public to be exempt from the data requirements referred to in §A of this regulation. In addition, non-Maryland hospitals may apply to the Commission for an exception or an extension to either the form or to the manner of these data requirements as provided for in COMAR 10.37.01.02 and .03. If a non-Maryland hospital fails to submit discharge data on all Maryland patients as required by the Commission, the matter shall be referred by the Commission to Maryland's Medical Assistance Program for appropriate action. Data Elements are as published in the Maryland Register and on the Commission's website (http://www.hscrc.state. md.us). Data submitted in accordance with this chapter are not public information pursuant to Health-General Article, §19-207(d), Annotated Code of Maryland. Summary studies, reports, or other compilations developed by the Commission or its staff from the data submitted in accordance with this chapter shall be public information except that disclosure may not be made in a way that the data furnished by a specific patient can be identified. The Commission shall prescribe the process for hospitals to submit corrections and revisions to the data on its website. Health-General Article, §§19-207, 19-211, 19-212, 19-215, and 19-216, Annotated Code of Maryland Effective date: January 1, 1983 (9:16 Md. R. 1605) Regulation .02J, K repealed and new Regulation .02A, B(10) and (11) adopted effective July 1, 1985 (12:13 Md. R. 1280) Regulations .01—.06 repealed effective January 1, 1986 (12:22 Md. R. 2105) Regulations .01—.06 adopted effective January 1, 1986 (12:22 Md. R. 2105) Regulation .01 repealed and new Regulation .01 adopted effective February 28, 2005 (32:4 Md. R. 411) Regulation .01-1 adopted effective February 7, 2000 (27:2 Md. R. 145) Regulation .02 repealed and new Regulation .02 adopted effective April 1, 1993 (20:5 Md. R. 514) Regulation .02 amended as an emergency provision effective July 1, 1998 (25:15 Md. R. 1183); amended permanently effective October 5, 1998 (25:20 Md. R. 1531) Regulation .02B amended effective September 1, 1986 (13:16 Md. R. 1827); November 3, 1986 (13:22 Md. R. 2400) Regulation .02B amended as an emergency provision effective November 17, 1986 (13:25 Md. R. 2653); emergency status expired March 1, 1987 Regulation .02B amended effective March 9, 1987 (14:5 Md. R. 580); August 1, 1994 (21:15 Md. R. 1306); December 4, 1995 (22:24 Md. R. 1894); February 10, 1997 (24:3 Md. R. 187); August 5, 2002 (29:15 Md. R. 1142); July 4, 2005 (32:13 Md. R. 1112); June 4, 2007 (34:11 Md. R. 972) Regulation .02B amended as an emergency provision effective July 1, 2007 (34:17 Md. R. 1506); amended permanently effective October 8, 2007 (34:20 Md. R. 1739) Regulation .03 repealed and new Regulation .03 adopted effective April 1, 1993 (20:5 Md. R. 514) Regulation .03 amended effective August 1, 1994 (21:15 Md. R. 1306); December 4, 1995 (22:24 Md. R. 1894); February 10, 1997 (24:3 Md. R. 187) Regulation .03 amended as an emergency provision effective July 1, 1998 (25:15 Md. R. 1183); amended permanently effective October 5, 1998 (25:20 Md. R. 1531) Regulation .03B, H amended as an emergency provision effective July 1, 2007 (34:17 Md. R. 1506); amended permanently effective October 8, 2007 (34:20 Md. R. 1739) Regulation .03F amended as an emergency provision effective November 17, 1986 (13:25 Md. R. 2653); emergency status expired March 1, 1987 Regulation .03F amended effective March 9, 1987 (14:5 Md. R. 580) Regulation .03G amended effective August 5, 2002 (29:15 Md. R. 1142) Regulation .03H amended effective July 4, 2005 (32:13 Md. R. 1112); June 4, 2007 (34:11 Md. R. 972) Regulation .06 amended as an emergency provision effective April 1, 1993 (20:5 Md. R. 514) Chapter revised effective March 9, 2009 (36:5 Md. R. 422) Regulation .01A, B amended as an emergency provision effective January 1, 2014 (40:24 Md. R. 2014); amended permanently effective March 3, 2014 (41:4 Md. R. 301) The purpose of these regulations is to enable the Commission to fully measure and compare hospital-specific performance on readmissions and to use the data to further enhance and strengthen the financial incentives linked with performance. In this chapter, the following terms have the meanings indicated. Terms Defined. “Health Information Exchange (HIE)” means an infrastructure that provides organizational and technical capabilities for the exchange of protected health information electronically among entities not under common ownership. “Health Services Cost Review Commission (Commission)” means the independent organization within the Maryland Department of Health that is responsible for reviewing and approving the rates for hospitals pursuant to Health-General Article, §19-201 et seq., Annotated Code of Maryland. “Maryland Health Care Commission (MHCC)” means the agency established by Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland. “Master Patient Index (MPI)” means an electronic database, created by the State-Designated HIE that maintains a unique index (or identifier) for every individual who has been, or who becomes, registered as a patient at a Maryland hospital. “State-Designated HIE” means an HIE designated by the MHCC. Effective December 1, 2011, each hospital under the jurisdiction of the Commission shall electronically connect to the State-Designated HIE to enable the Commission to fully measure hospital-specific performance on readmissions using the HIE’s MPI. Each hospital shall establish connectivity with the State-Designated HIE over a secure and encrypted connection. This connectivity shall be established using industry standards specified by the State-Designated HIE. Each hospital under the jurisdiction of the Commission shall collect and electronically submit to the State-Designated HIE the data elements as published in the Maryland Register and on the Commission’s website (http://www.hscrc.state.md.us). The format and data time period for submission shall also be published in the Maryland Register and on the Commission’s website. Data submitted in accordance with this chapter are not public information pursuant to Health-General Article, §19-207(d), Annotated Code of Maryland. The Commission will take reasonable steps to safeguard and protect the confidentiality of protected health information consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Maryland Confidentiality of Medical Records Act, and all other applicable State and federal laws and regulations. Summary studies, reports, or other compilations developed by the Commission or its staff from the data submitted in accordance with this chapter shall be public information except that disclosure may not be made in such a way that the data furnished can lead to the identification of an individual. The Commission shall prescribe on its website the process for a hospital to submit corrections and revisions to the data it has submitted. Data submitted in accordance with this chapter shall be considered a required report under COMAR 10.37.01.03N. Health-General Article, §§19-143, 19-207, 19-212, 19-215, and 19-216, Annotated Code of Maryland Effective date: September 19, 2011 (38:18 Md. R. 1077) Public meetings of the Commission may be held where and when the Commission directs for any authorized purpose, provided, however, that at least six meetings are held per year. A quorum need not be present in order for the Commission to hold a public meeting. If, however, less than a quorum is present at any public meeting, matters submitted for a vote shall be deferred. The Chairman, or in his absence, the Vice-Chairman of the Commission or a designee shall preside at public meetings which may be called to order when the above presiding officer or his designee is in attendance. The Commission shall transact routine business and shall sit for the consideration of any and all matters which may properly be brought before it at the meeting. The Executive Director of the Commission in consultation with the Chairman shall be responsible for developing the agenda for each public meeting. Minutes of the meeting shall be taken by the Commission and made available for public inspection at the offices of the Commission, during ordinary business hours. Each Commission member, except the Chairman, shall be entitled to one vote on each matter submitted to a vote at the meeting. Voting shall be in person or by proxy. The Chairman shall vote only to break a tie or cast a fourth concurring vote. During the time between public meetings, each Commission member shall be entitled to one vote on each matter submitted to vote. A public meeting may be adjourned by a majority of those Commission members present in person. Health-General Article, §19-206, Annotated Code of Maryland Effective date: May 11, 1977 (4:10 Md. R. 767) In this chapter, the following terms have the meanings indicated. Terms Defined. “Automated clearing house (ACH)”, as defined in COMAR 03.01.02.01B, means a central clearing organization that operates as a clearing house for transmitting or receiving entries between banks and bank accounts, and authorizes an electronic transfer of funds between banks or bank accounts. “Commission” means the Health Services Cost Review Commission. “Comptroller” means the Comptroller of the Treasury or the Comptroller's designee. “General Accounting Division” means the Fiscal Services Administration for the Maryland Department of Health. “Health Services Cost Review Commission Fund” means the special fund established under Health-General Article, §19-207.1(d), Annotated Code of Maryland. “Hospital” means an institution that is licensed by the Maryland Department of Health as an acute general hospital. “Hospital Uncompensated Care Fund” means the monies that are collected from hospitals for the equitable financing of hospital uncompensated care and which are a discrete part of the Health Services Cost Review Commission Fund. “Interest” means the investment earnings generated from the investment and reinvestment of the monies of the Hospital Uncompensated Care Fund which are separately held by the Treasury, accounted for by the Comptroller, and retained to the credit of the Health Services Cost Review Commission Fund. “Mark-up” means the mechanism used to increase hospital rates to allow for payer differentials, working capital (prompt payment) differentials, and a provision for uncompensated care. “Remittance” means the amount each hospital remits to the General Accounting Division pursuant to the predetermined formula established by the Commission to provide funding for the Commission's Hospital Uncompensated Care Fund. “Special rate adjustment” means an adjustment to a hospital's rates, which will bring the hospital's uncompensated care provision of its mark-up to the Statewide uncompensated care average. “Treasury” means the State Treasury. “Wire transfer” means an electronic transaction in which a hospital, through the hospital's bank and an automated clearing house, originates an entry crediting the Health Services Cost Review Commission Fund's bank account and debiting the hospital's bank account on the same day the transaction is initiated. The Commission shall make a special rate adjustment to the uncompensated care provision of each hospital's mark-up to pay for the financing of the reasonable costs of hospital uncompensated care. The Commission shall notify hospitals in writing of the amount due to be remitted in a given month before the first day of that month. On or before the first business day of each month, the Commission shall direct the General Accounting Division to arrange for the collection of the amount due to be remitted by individual hospitals. This amount shall be based on the difference between a hospital's uncompensated care provision in its mark-up and the Statewide uncompensated care average. The Commission shall, at the same time, notify the General Accounting Division in writing of the: Hospitals due to remit for that month; Amount of the remittance for that month; Hospitals to receive payments from the Hospital Uncompensated Care Fund for that month; Amount to be disbursed to hospitals from the Hospital Uncompensated Care Fund in that month; and The appropriate banking account information from each hospital in order to debit or disburse funds electronically by wire transfer. All funds collected shall be transferred to the Hospital Uncompensated Care Fund. By January 1, 2009, each hospital shall provide the Commission with sufficient banking information to facilitate the collection and disbursement of funds by the ACH or other wire transfer method. Each hospital shall initiate or authorize the ACH or other wire transfer method as directed by the Commission. On or before the 5th business day of each month, each hospital identified as due to remit monies in accordance with the provisions of these regulations shall make payment into the Hospital Uncompensated Care Fund in the manner prescribed by the Commission. On or before the 5th business day of each month, the Comptroller shall transfer monies out of the Hospital Uncompensated Care Fund and distribute monies to hospitals in the manner specified by the Commission. Funds generated through the special rate adjustment and the remittance due may only be used to finance the delivery of hospital uncompensated care. Interest earned from the monies collected shall be retained to the credit of the Hospital Uncompensated Care Fund. Interest earned may be used to pay for the reasonable expenses associated with implementation of the alternative methodology approved by the Commission for financing the reasonable costs of hospital uncompensated care. The Commission may impose penalties of up to 5 percent of the amount of an underpayment, unless an extension is granted as provided in §E of this regulation. A hospital that violates the provisions of Regulation .03 of this chapter shall, in addition to the penalties imposed under §A of this regulation, be subject to an annualized interest charge of 3 percentage points above the most recent average prime rate of interest, as published in the “Money Rates” section of the The Wall Street Journal, on the unpaid balance. In addition to the penalties the Commission may impose on a hospital that fails to pay the remittance in a timely manner, the Commission may refer the hospital's delinquent account to the Department of Budget and Fiscal Planning's Central Collection Unit pursuant to the procedures in State Finance and Procurement Article, Title 3, Subtitle 3, Annotated Code of Maryland. A hospital may file a written request with the Commission for a reasonable extension of time to make payment if the extension request is: Made in writing to the attention of the Executive Director; Supported by sufficient justification; and Made at a reasonable time before the due date of a required payment. The Executive Director shall respond promptly in writing to the requesting hospital upon receipt of the request by either approving or disapproving the request. Extensions will be granted only for valid reasons. Health-General Article, §§19-207, 19-207.1, 19-207.3, and 19-214, Annotated Code of Maryland Effective date: February 10, 1997 (24:3 Md. R. 188) Regulation .01 amended effective March 9, 1998 (25:5 Md. R. 369); May 31, 1999 (26:11 Md. R. 855) Regulation 01B amended as an emergency provision effective December 1, 2008 (36:2 Md. R. 97); amended permanently effective March 9, 2009 (36:5 Md. R. 423) Regulation 02 amended as an emergency provision effective December 1, 2008 (36:2 Md. R. 97); amended permanently effective March 9, 2009 (36:5 Md. R. 423) Regulation 03 amended as an emergency provision effective December 1, 2008 (36:2 Md. R. 97); amended permanently effective March 9, 2009 (36:5 Md. R. 423) Regulation .04A, C amended effective March 9, 1998 (25:5 Md. R. 369); May 31, 1999 (26:11 Md. R. 855) Regulation 04A, C amended as an emergency provision effective December 1, 2008 (36:2 Md. R. 97); amended permanently effective March 9, 2009 (36:5 Md. R. 423) Regulation .05 recodified to Regulation .06 and new Regulation .05 adopted effective March 9, 1998 (25:5 Md. R. 369) Regulation .05 amended effective May 31, 1999 (26:11 Md. R. 855) Regulation 05 repealed as an emergency provision effective December 1, 2008 (36:2 Md. R. 97); repealed permanently effective March 9, 2009 (36:5 Md. R. 423) Regulation 06 amended as an emergency provision effective December 1, 2008 (36:2 Md. R. 97); amended permanently effective March 9, 2009 (36:5 Md. R. 423) “Burden of proof” means the burden of persuasion by the preponderance of the evidence. “Commission” means the Health Services Cost Review Commission. “Executive Director” means the Executive Director of the Commission, or in his absence, the Commission staff member designated to act in his stead. “Opinion” means a written statement setting forth the reasons and grounds why the writer of the statement believes that certain actions should be taken or decisions or recommendations made. “Order Nisi” means an order of the Commission that certain actions shall be taken or that certain matters are approved as of a future date, thereby permitting parties affected by the Order Nisi to make any objections they may have known to the Commission. Partial Rate Application. “Partial rate application” means a request by a hospital for the amendment or establishment of a single approved rate. “Partial rate application” includes, but is not limited to, those requests enumerated in Regulation .03B(4) of this chapter. “Publish” means the insertion of a public notice concerning proposed actions, including but not limited to public hearings, in a newspaper or newspapers in general circulation in the community in which the hospital affected is located, and, if the public notice relates to a public hearing, in the Maryland Register at least 15 days before the date of the public hearing. “Rate application” and “application” mean a hospital application for rate approval, to be submitted as specified in these regulations. “Recommendation” means a written statement from the Commission's staff to the Commission, advocating a resolution of issues or approval, disapproval, or modification of certain hospital rates and procedures for evaluating the rates. “Regression analysis” means a statistical technique used to measure and control for the effect of selected independent variables (for example, percentage of Medicaid revenue) on one dependent variable (for example, bad debts). “Uncompensated care” means care provided for which compensation is not received (that is, any combination of bad debts and charity care), and as more fully described in the Commission's Accounting and Budget Manual for Fiscal and Operating Management which is incorporated by reference at COMAR 10.37.01.02. “Value of the substantial, available, and affordable coverage (SAAC) differential” means the difference between the amount paid out by SAAC-approved nonprofit health service plans, health insurers, and health maintenance organizations on behalf of SAAC enrollees to hospitals, and what they would have paid to hospitals absent the differential. The Alternative Rate Setting Method (ARM) Manual (1998) is hereby incorporated by reference. The rate review system, otherwise known as the Accounting and Budget Manual for Fiscal and Operating Management, shall consist of: The rate review forms; and Instructions for completion of the forms. The rate review system is incorporated by reference in COMAR 10.37.01.02. A hospital's rate review system and a schedule of published rates shall be filed by the last day of the third month after the close of the hospital's fiscal year. A hospital may not file a full rate application with the Commission until the Commission staff is able to determine through analysis that the data used to evaluate a full rate application has not been substantially affected by the COVID pandemic. During this interim period, a hospital may seek a rate adjustment under any other administrative remedy available to it under existing Commission law, regulation, or policy. In no event shall this moratorium continue in effect beyond June 30, 2023. Once the moratorium is lifted, a hospital may file a regular rate application at any time if: The rates being requested are not the subject of a hospital-instituted case pending before the Commission; or The subject hospital has not obtained permanent rates through the issuance of a Commission rate order within the previous 365 days. Full Rate Application. “Full rate application” means a regular rate application which requests the amendment of more than one previously approved rate. In order for a full rate application to be docketed, it shall comply with a template for such applications as prescribed by the Commission staff and shall: Enumerate the services for which new rates are being requested, listing present and proposed rates; Be accompanied by appropriate supporting documents, including: The Annual Report of Revenues, Expenses, and Volumes projected and explained (e.g., how much of the requested increase relates to inflation, volumes, and other factors) for the period for which the hospital requests new rates; Any audited financial statements over the most recent 5 years not yet filed with the Commission, plus the most recent unaudited financial statements for the current period, which are available at the time of the filing of the full rate application; An Excel file listing and summarizing balance sheets, statements of operations and changes in net assets, and statements of cash flow for the last 5 years per the audited financial statements along with a narrative explaining any major changes; An Excel file listing the information contained within the Annual Report RE schedules for the last 5 years breaking out regulated and unregulated revenues and expenses by category and in total; A detailed history of HSCRC-approved revenue and actual revenue for the hospital for the last 2 calendar years; A detailed history for the most recent 4 Rate Years of HSCRC-approved GBR revenue and actual revenue and volumes, in addition to any approved and actual revenue and volumes available at the date of the filing of the full rate application. The history of approved and actual revenue changes should detail the basis of the changes in approved and actual revenue including allowed inflation and all other factors; An identification of related organizations (i.e., an organization related to the hospital through some type of control or ownership), including subsidiaries of the hospital as well as hospitals that are part of the same hospital system as the applicant hospital. For applicant hospitals that are part of a system, the hospital may be required to submit financial and other information related to the system hospitals, including any system transactions among the system hospitals, which may affect the financial condition of the applicant hospital; A listing of any services provided by related organizations including the amount charged to the applicant hospital for the services; A listing of any transfers of funds to or from a related organization including an explanation of such transfers; Copies of the two most recent Medicare Cost Reports, including any home office cost report files — the Interns and Resident Information System report (IRIS) files, and the wage and occupational mix files, along with any adjustments and corrections; Reconciliations of inpatient and outpatient volumes and revenue submitted in the HSCRC abstract data to the departmental revenue and statistics submitted monthly for the last 3 years; In Excel, listing of Outpatient drugs accounting for at least 80 percent of the Hospital’s total outpatient drug expenses, with applicable HCPCS codes for last 3 years, including frequency of charges, amount of charges and units billed, Average Sales Price at the end of each year and applicable 340B discounts and an estimate of billed charges for unlisted drugs; For profits or losses associated with the support of physician practices, the applicant hospital may be required to provide a detailed accounting of those profits or losses over time. Additional information regarding compensation, subsidies and other forms of financial support provided to physicians may be required following staff’s initial review to the extent that these profits or losses have a material impact on the financial condition of the applicant hospital; A supporting document, in Excel, that compares the requested departmental rates of the applicant hospital to that hospital’s current departmental rates. The supporting document should also compare these current and requested departmental rates to those of other HSCRC-regulated hospitals located in the Primary Service Area (PSA) of the applicant hospital. If no other regulated hospitals are located in the applicant hospital’s PSA, then the comparison should be made to Statewide median departmental rates; and An accounting of the amounts reported by the applicant hospital to the HSCRC regarding its uses of population health infrastructure money included in rates; Include a description of the rate adjustments that are being requested in the full rate application; Include specific detail and substantiation of any circumstances the applicant hospital cites as unique to its facility, which would require revenue in excess of the amount currently provided in its approved regulated revenue; Describe in detail what the applicant hospital has specifically done consistent with the All-Payer Model to reduce or eliminate unnecessary or potentially avoidable utilization. For purposes of this regulation, unnecessary or potentially avoidable utilization means the utilization of health care items and services, including care furnished to treat complications during a hospital admission, that may be avoided through improved efficiency, care coordination, or effective community-based care, or that is not medically necessary or evidence-based care. The Staff may request additional information as needed; Provide estimates for the next 5 years of reductions in utilization that will be accomplished through care redesign initiatives; Provide a history of denials for the most recent 3 years, including any year-to-date figures; and Any additional information the Staff may request that bears directly on the hospital’s request for rate relief and its financial condition. The provisions of §B(2) of this regulation may be waived by staff if the application applies only to: A request filed for a change in the applicant hospital’s uncompensated care allowance; A request for rates to cover government-mandated or similar action affecting more than one previously approved rate for which the staff believes the provisions of §B(2) of this regulation are not necessary; or A request for rates associated with a Certificate of Need-approved capital project, which request may be considered to be a “partial rate application” by staff. Uncompensated Care Policy. The Commission's rate-setting methodology shall include in the rates of each hospital a provision for a reasonable level of uncompensated care provided at the hospital. The Commission may use a regression analysis or other statistical method to establish the reasonable level of uncompensated care. In establishing a reasonable level of uncompensated care in a full rate review, the Commission shall consider for each hospital the: Amount of uncompensated care actually incurred; Predicted amount of uncompensated care; and The hospital's requested amount. A hospital may request a change in its approved provision of uncompensated care to the predicted amount by means of a partial rate application provided the request is revenue neutral. The provisions of Regulation .03B(2) of this chapter may be waived by staff in the review of a partial rate application. A hospital may file a partial rate application with the Commission at any time, consistent with the provisions of Regulation .03A of this chapter. A partial rate application is not a contested case under the provisions of the Administrative Procedure Act. The Commission shall act on a docketed partial rate application within the time frames established for a full rate application that does not involve a public hearing, consistent with Commission law and regulation. A hospital that has been denied its request for a partial rate change may file a full rate application with the Commission in accordance with Commission law and regulation. The Commission may order a review of a hospital's established rates at any time, as it deems necessary and proper. This order, provided it orders the review of any rate or charge, may constitute a Commission-initiated rate proceeding. In reviewing a hospital’s established rates during a Commission-initiated rate proceeding or while reviewing a hospital’s full rate application, the Commission shall consider the hospital’s performance since the implementation of the All-Payer Model Agreement with the federal government, which took place in February 2014. In evaluating the reasonableness of a hospital's permanent rate structure, the Commission shall use an Inter-hospital Cost Comparison (ICC) methodology, which compares the costs of the hospital to those costs, including adjustments for reasonableness and efficiency, of its peer hospitals, with appropriate adjustments to reflect changes in the hospital’s volume since the beginning of the new All-Payer Model Agreement and the inception of the hospital’s revenue agreement, as the foundation of its review of the full rate application. The staff shall make modifications to the ICC which are needed to properly reflect any additional factors that are relevant to the determination of a reasonable cost level that should be reflected in the hospital’s approved regulated revenue. The ICC analysis does not constitute a strict, unalterable or absolute methodology. It shall be modified as needed to give proper attention to the particular circumstances of the hospital, and the staff shall give due consideration to information provided by the hospital in determining the appropriate rate levels and rate structure for the hospital. The ICC shall take into account, in the establishment of appropriate rate levels, those factors for which the hospital will not be held accountable such as special grants from the Commission, assessments, uncompensated care levels, and characteristics of the population in the hospital’s primary service area. Factors considered in the ICC methodology may evolve during the course of full rate reviews. The Commission shall take into account the specific circumstances of the applicant hospital, and staff shall make the key contents, analytic steps, and findings of such reviews available to all hospitals and the public. When reviewing a full rate application filed by a hospital that is owned or controlled by a hospital system that also owns other hospitals located in Maryland, the Commission may take into account the financial situation of the other hospitals in the system including their profitability and any shifts of services, volume, revenues or assets between the hospital and the other hospitals or related organizations of the system. The final rates that are approved by the Commission for a nonprofit hospital’s permanent rate structure shall allow the hospital to charge reasonable rates that will permit it to provide, on a solvent basis, effective and efficient service that is in the public interest. The final rates that are approved by the Commission for a proprietary profit-making hospital’s permanent rate structure shall allow the hospital to charge reasonable rates that will permit it to provide effective and efficient service that is in the public interest and include enough allowance for and provide a fair return to the owner of the hospital. The Commission shall set rates for the applicant hospital consistent with the All-Payer Model approved by the federal Center for Medicare and Medicaid Innovation. The Global Budget Revenue (GBR) methodology implemented by the Commission effective January 1, 2014, establishes reasonable revenue levels for Maryland's general acute hospitals, which will enable them to improve quality and efficiency on a solvent basis within the constraints imposed by the All-Payer Model. In setting reasonable revenue levels, the Commission shall take into account a number of factors. These may include, but are not limited to the following: The casemix severity and reasonable utilization of the hospital’s patients; The historical charges of the hospital; The statutory requirement regarding the reasonable relationship between costs and charges; The hospital’s payer mix; The reasonable uncompensated care requirements of the hospital; The reasonable Graduate Medical Education (GME) costs of the hospital as determined by the Commission; Appropriate adjustments, if any, associated with exceptional or outlier cases as defined by the Commission; Wage levels at the hospital and at other hospitals in the geographic area of the hospital and elsewhere in Maryland; Adjustments for quality improvement and value-based payment programs applicable to the hospital; Reasonable infrastructure funding for care management and care coordination for hospital patients; The annual update factor; The proportion of unnecessary care, including Potentially Avoidable Utilization (PAU) at the hospital; and The performance of the State as a whole under the All-Payer Model. The GBR shall be implemented through a written agreement entered into by the Commission and each individual general acute hospital. This agreement and any addenda thereto, which shall be annual and renewed automatically, shall set forth all relevant provisions governing the GBR including, but not limited to, performance corridors; interim rate adjustments; the exclusion or special treatment of certain cases; the treatment of volume changes, including those involving residents of Maryland and other patients; the penalties associated with failure to comply with the terms of the GBR agreement; interim revenue limits; care redesign requirements; and other changes to the agreement that may be needed from time to time. A hospital that enters into a GBR agreement shall submit a signed copy of the agreement to the Commission’s offices within 60 days after it is initially approved by the Commission. A hospital that is party to the addendum shall submit a signed copy of the addendum to the Commission’s offices within 60 days from the issuance of the addendum. Failure to submit the signed GBR agreement or the signed addendum in a timely manner, absent an extension granted by staff, may subject the hospital to penalties under COMAR 10.37.01.03R. Thereafter, on an annual basis, the hospital shall receive an updated rate order. A hospital that disagrees with a proposed GBR may file a full rate application with the Commission in accordance with Regulation .03 of this chapter. For purposes of this regulation, the following definitions apply: “Annual update factor” means the amount by which total State hospital revenue may increase in a rate year. “Demographic adjustment” means the percentage increase in allowed revenue related to changes in population and the age/sex mix of the population residing in the hospital’s primary service area, net of any reductions. “Factor cost inflation” means increases in the costs of goods, services, wages, and salaries experienced by the hospitals as calculated by the Commission for the most recent period for which data are available preceding the year for which the Commission calculates case target updates. “Hospital update” means the amount by which an individual hospital’s approved GBR revenue changes in a particular rate year (i.e., July 1—June 30). “Market shift adjustment” means the rate adjustment applied by the Commission, which increases or decreases the approved GBR revenue of a hospital to reflect changes in volume at the hospital for which there was a corresponding change in volume at another Maryland hospital or other provider. Annual Update Factor. On or before July 1 of each year, the Commission shall establish an annual update factor for the purpose of adjusting the GBR revenue of each individual hospital. The annual update factor shall be designed to reflect projected factor cost inflation, an allowance for certain volume adjustments, productivity adjustments, the revenue constraints included in the All-Payer Model Agreement and other relevant factors, demographic adjustments, market shift adjustments, and other appropriate adjustments. If after approving an update factor for a given year, a hospital or hospitals collectively exceed their approved revenue, the annual update factor may be reduced in future years to recoup the excess revenue growth. Similarly, if a Maryland hospital or hospitals collectively fall below their approved revenue for a given year, the annual update factor may be adjusted accordingly in future years. If Maryland hospitals accrue a national growth reduction for 2 consecutive years, in the following year the annual update factor shall be reduced by the first of the 2-year national growth reduction. Except as provided in §D of this regulation, the annual update may not be less than 1 percent. The technical provisions of the methodology used to convert the annual update factor into the hospital update for the next rate year shall be fully described and publicly disseminated on or before July 1 of each year, allowing sufficient time for comment and implementation. Corrective Action. If, at any time, the Commission estimates that the financial constraints or other terms imposed by the All-Payer Model Agreement are at risk of being violated (based on modelling using the CMS actuary’s most recent projections and Health Services Cost Review Commission analysis of Medicare payments data), the Commission may take immediate and appropriate corrective action as it deems necessary and proper to meet the Medicare savings requirements and limits on growth in Medicare payments and prevent any further deterioration in compliance with the Model Agreement. The Commission shall provide sufficient notice and opportunity for comment before taking corrective action. This comment opportunity does not constitute a contested case within the meaning of the Administrative Procedure Act. The provisions of this regulation apply to all Maryland's general acute care hospitals from July 1, 2014, and thereafter. Compliance and Penalties. GBR compliance shall be monitored during the agreement period. Penalties shall be assessed prospectively at the beginning of the next period. Penalties shall be based on the corridors specified in the GBR Agreement. The Commission may issue a general notice setting forth circumstances under which a hospital may obtain a temporary change in rates. The rates, if approved or modified, shall be effective before the rate review procedure set forth in these regulations, but not before the date of application. A hospital may apply at any time for a temporary change in rates provided that one of the following conditions is satisfied: A decline in the hospital's experienced or projected net revenues, due to factors beyond the hospital's control, requiring funds beyond those normally available; An increase in the hospital's experienced or projected expenses, due to factors beyond the hospital's control, requiring funds beyond those normally available; or A hospital's expenses from regulated services exceed its revenues from regulated services, or the hospital's financial integrity is otherwise jeopardized (for example, for breaching its bond covenants). The Commission and its staff shall review the application and consult with the hospital as to the necessity for the temporary change in rates and the amount of the change required. Designated interested parties shall have 6 working days from the filing of the application to submit comments to the Commission. Within 12 working days from the filing of the application, the Commission shall issue its order: Denying the temporary change in rates and stating the grounds therefor; or Granting a temporary change in rates, stating: The amount of the temporarily changed rates, which may or may not be the same as the rates set forth in the hospital's application; The necessity for the temporary change in rates; That a regular rate review proceeding on the proposed rates will be conducted by the Commission as soon as practicable; The availability of copies of the order at the offices of the Commissioner; and The availability of the record of the temporary rate application for inspection at the Commission's office during ordinary business hours. The Commission order denying or granting the temporary change in rates shall be published and copies forwarded to: The hospital; Designated interested parties; and Persons writing to the Commission requesting a copy of the order. In conducting an expedited review to establish a temporary rate for both inpatient and outpatient services, the Commission shall consider the hospital’s financial condition in addition to its relative efficiency and effectiveness in its performance under the Total Cost of Care Model. A temporary rate approved by the Commission may not result in regulated revenue exceeding regulated expenses in the most recently completed fiscal year. A temporary change in rates is subject to the Commission's final rate order in the regular rate review proceeding, which may be effective as of the date of the temporary rate order. At any time on or after July 1, 1974, a hospital may file a written application with the Commission requesting an alternative method for submitting or reviewing any or all of its rates and charges, specifying the reasons for and details of the alternative methods. If warranted by the circumstances set forth in the application, the Executive Director may grant a temporary approval of an alternative method of rate determination. The procedure for submitting and reviewing an application under an alternative method of rate determination shall follow as closely as possible the procedure for a regular rate application, except that the time periods and limitations set forth in these regulations do not apply to an application for an alternative method of rate determination. At anytime after the approval of an alternative method of rate review by the Executive Director, the Commission may initiate further proceedings to determine the hospital's continuing qualification for the alternative method of rate determination. ARM System. The Commission may implement a system providing for alternative rate setting methods (ARM) which would permit hospitals to accept financial risk for the provision of hospital services under certain conditions and circumstances. The implementation of an ARM system shall be consistent with the principles of equity and access embodied in the Commission's all-payer rate setting system. The ARM Manual shall set forth the process and requirements associated with the ARM system. Required Reports under ARM System. A hospital granted approval for an alternative method of charging under this regulation is required to file quarterly reports and annual reports, to include but not be limited to those listed below in this section, in order to determine that the hospital continues to qualify for the alternative method of rate determination. Quarterly Reports. The following reports shall be completed in the form prescribed by the Commission and submitted to the Commission within 30 days after the end of each hospital's calendar quarter: Statistical Data Summary—Each Capitation or Risk-Sharing Contract; Statistical Data Summary—Each Fixed-Price Contract; Statistical Data Summary—Other; Revenue Summary—Each Capitation or Risk-Sharing Contract; Revenue Summary—Each Fixed-Price Contract; and Revenue Summary—Other. Annual Reports. The following annual reports shall be completed in the form prescribed by the Commission and submitted to the Commission within 90 days after the end of the appropriate fiscal year: Statement of Revenue and Expense—Each Capitation or Risk-Sharing Contract; Statement of Revenue and Expense—Each Fixed-Price Contract; Statement of Revenue and Expense—Other; Audited Statement of Revenue and Expense—Contracting Entity; and Audited Balance Sheet—Contracting Entity. Filing of Reports/Extension. A hospital required to file the reports in this section may request a reasonable extension of time for filing, if the extension request is: Made in writing to the attention of the Executive Director; Supported by sufficient justification; and Made at a reasonable time before the due date of a required report. The Executive Director shall respond promptly in writing to the requesting hospital upon receipt of the request by either approving or disapproving the request. Extensions will be granted only for valid reasons. Any required report submitted by a hospital that is substantially incomplete or inaccurate shall be considered untimely filed. Time for Filing. An application for an alternative rate application shall be filed at least 30 days before the proposed effective date of the alternative rate. Penalties. The Commission may impose penalties of up to $1,000 per day for failing to file reports as required under this section. The Commission may refuse to grant a rate increase to a hospital that does not file a report as required under this section. A fine assessed for failure to file an alternative rate application on a timely basis shall begin as of the date the application should have been filed. Funding for Health Information Technology. The Commission may adjust a hospital's rates for health information technology (HIT) projects in conjunction with action taken by the Maryland Health Care Commission (MHCC) under COMAR 10.25.13. Upon receipt of a recommendation for funding from the MHCC, the Commission's staff shall: Review the information presented; Consult with appropriate parties; and Recommend to the Commission approval, denial, or modification of the MHCC recommendation. In deciding the course of action to follow on an MHCC HIT project recommendation, the Commission and its staff shall consider, among other things, the following criteria: The basis for the MHCC recommendation; The applicant's statement of the purpose, mission, vision, goals, and measurable objectives of the project; The planned approach, including: An explanation of how the project's goals and objectives will be met; The technical strategy of the project; What activities will be used; What personnel will be needed; and How that personnel will be utilized; How the project will be evaluated, as well as specific measurement strategies; A timeline that includes the start and end dates of the project and a schedule of activities; The credentials of the entity and participating individuals, including information that demonstrates their background and ability to carry out the project successfully; The potential of the project to enhance the value of health care in Maryland, such as improving health care outcomes and reducing health care costs; Information that demonstrates why the project is needed; and A budget that details cost projections for the project that is specific, reasonable, realistic, accurate, and flexible. Decision. Based on its consideration of the above-stated criteria and staff's recommendation, the Commission shall decide on the nature, extent, terms, and conditions of any rate adjustment approved. The decision of the Commission on an MHCC recommendation for HIT funding is final. A request for funding under this section is not a contested case under the Administrative Procedure Act. At least 60 days before the operational opening of a new hospital, a revenue center, or a new service within a hospital whose projected annual operating cost exceeds $100,000, the hospital shall file a rate application for the requested rates. This application shall be supported by financial data presented in the format of the Commission's rate review system. If an existing hospital expends its operations so that the number of in-patient beds is increased by 20 percent or more, and if a rate application is filed pertaining to the expended facilities and providing for an occupancy rate for the expanded facilities of the hospital at an amount below the target occupancy established by the Commission, the Commission may require the filing of additional information projecting the hospital's expanded facilities' activity levels for the first 5 years of their operation. Definitions. In this regulation, the following terms have the meanings indicated. Terms Defined. “At the hospital” means a service provided in a building on the campus of a hospital in which hospital services are provided. “Health care provider” means an individual who is licensed, certified, or otherwise authorized by law to provide health care services under Health Occupations Article, Annotated Code of Maryland. “Telehealth services” means the delivery of health care services provided through the use of interactive audio, video, or other telecommunications or electronic technology by a health care provider at a hospital to a patient at a location other than at the hospital, or to a patient at the hospital where the provider is at a location other than the hospital, which enables the patient to interact with the health care provider at the time the health care services are provided. A service at the hospital is: Presumed to be an outpatient service; and Subject to rate regulation. In accordance with Health-General Article, §19-201, Annotated Code of Maryland, the Commission’s rate-setting jurisdiction extends to outpatient services provided at the hospital. Outpatient services associated with the federal 340B Program under the federal Public Health Service Act provided in a department of a regulated hospital that, on or before June 1, 2015, is under a merged asset hospital system, and which are physically located at another regulated hospital under the same merged asset hospital system, shall be subject to the rate-setting jurisdiction of the Commission. The Commission may begin setting rates for these services in anticipation of the hospital’s obtaining provider-based status for purposes of the 340B Program. A hospital that desires an exception to the presumption stated under §C of this regulation must receive a determination under the provisions of this regulation. Commission Approval. A hospital may not charge a Commission-approved rate for an outpatient service without prior Commission or Commission staff approval. A hospital may not open a new outpatient service, relocate an existing outpatient service, or convert an existing outpatient service from regulated or unregulated status without a prior determination from the Commission’s staff as to whether the service is being provided at the hospital. A request for determination shall be made in writing at least 60 days before the contemplated action. Upon request for an exception under §D of this regulation, the Commission's staff shall: Review the information presented; Consult with appropriate parties; Visit the site of the service as it considers necessary; and Notify the hospital of its determination as soon as practicable. In deciding whether an outpatient service is at the hospital, the Commission staff may consider, among other things, the following criteria: Location of the entrances; Location and signage of parking; Location and language of signage at entrances, within buildings, on the campus, and in parking areas effectively alerting the public that a given building or service is either at the hospital or not at the hospital; Location of registration, changing, and waiting areas; Whether billing reflects clearly that the service is rate regulated or not rate regulated; Whether any physical connection from an unregulated facility to the hospital, such as tunnels, hallways, covered walkways, elevators, or connecting bridges, will be restricted to hospital staff and physician use in order to ensure that patients and visitors do not have access to the unregulated facility from the hospital; Whether there is any duplication of an unregulated service within the hospital in order to avoid inappropriate patient steering; Whether there is any inappropriate mixing of regulated and unregulated services in the same building, which would tend to have the effect of confusing patients about the regulated or nonregulated status of a given service being provided; and Whether any Medicare Part B physician's service being provided in an unregulated building also includes components of a Medicare Part A hospital service that would be reasonably expected by a patient to fall under Commission rate-setting jurisdiction. Based on consideration of the criteria stated in §G of this regulation, the Commission's staff shall make its determination on the request made under §E of this regulation. A hospital that fails to obtain or violates a staff determination on the hospital status of a given service may be subject to fines for inaccurate reporting under COMAR 10.37.01.03R and paybacks for inappropriate charges made during the time a staff determination on an outpatient service was not obtained or adhered to. A request for a determination under this regulation is not a contested case under the Administrative Procedure Act. A hospital may not bill a separate hospital facility fee when a health care provider who provided telehealth services is authorized to bill independently for the professional services rendered. The delivery of telehealth services as described in §A(2) of this regulation constitutes outpatient services provided at the hospital. Definition. In this regulation, “freestanding medical facility” means a freestanding medical facility licensed under Health-General Article, Title 19, Subtitle 3A, Annotated Code of Maryland. The following outpatient services provided at a freestanding medical facility are considered hospital services under Health-General Article, §19-201, Annotated Code of Maryland: Emergency Services; Observation Services; and Associated Ancillary Services, such as laboratory, radiology, imaging, EKG, and Medical/Surgical Supplies and Drugs. In accordance with Health-General Article, §19-201, Annotated Code of Maryland, the Commission’s rate-setting jurisdiction extends to those outpatient services provided at a freestanding medical facility, as designated by the Commission. A freestanding medical facility or a proposed freestanding medical facility that desires to provide a service not designated in §B of this regulation (an undesignated service) must receive a determination under the provisions of this regulation. Commission Approval. A freestanding medical facility may not charge a Commission-approved rate for an undesignated service without prior Commission staff approval. A freestanding medical facility may not open a new outpatient service, relocate an existing outpatient service, or convert an existing outpatient service from regulated or unregulated status without a prior determination from the Commission’s staff as to whether the service constitutes a hospital service subject to Commission rate regulation. A request for determination shall be made in writing at least 60 days before the contemplated action. Upon request for a determination, the Commission’s staff shall: Review the information presented; Consult with appropriate parties; Visit the site of the service as it considers necessary; and Notify the freestanding medical facility of its determination as soon as practicable. In deciding whether the service constitutes a hospital service subject to Commission rate regulation, Commission staff shall consider, among other things, the following criteria: Cost of the service; In consultation with Maryland Health Care Commission (MHCC) staff, access to and need for the service in the community; Feasibility of providing the outpatient service in the community on an unregulated basis; and Impact of the service on the All-Payer Model including, but not limited to, the Total Cost of Care limitations as prescribed in the All-Payer Model Agreement with the Center for Medicare and Medicaid Innovation. Based on the consideration of the criteria stated in §G of this regulation, the Commission staff shall make its determination on the request made under §E of this regulation within a reasonable period of time, taking into account, among other things, whether either a Certificate of Need application to establish a freestanding medical facility or a request for exemption from Certificate of Need to convert a licensed general hospital to a freestanding medical facility is pending before the MHCC and, if so, the time frame for staff to comment to MHCC on the financial feasibility of the proposed project. A freestanding medical facility that fails to obtain, or violates, a staff determination on the regulated status of a given service may be subject to fines for inaccurate reporting under COMAR 10.37.01.03R and paybacks for inappropriate charges made during the time a staff determination on an outpatient service was not obtained or adhered to. Each rate application shall include a list of services for which new rates are being requested, a list of the present and requested rates, and shall be based on the currently filed or required rate review system. The application may be filed by private messenger at the Offices of the Commission, or may be filed by registered mail, return receipt requested, at the following address: Health Services Cost Review Commission 4160 Patterson Avenue Baltimore, Maryland 21215 Docketing. When a valid rate application is received, as per the above regulations, it shall be entered on the Commission docket and a file opened. Each rate application shall be given an annual docket number and a consecutive page number in the docket. Each rate application shall be given a consecutive file number. A regular rate application file number shall be noted “R”. The file number of an order authorizing Commission investigation and review of established rates shall be noted “C”. A temporary rate application file number shall be noted “I”. An alternative method of rate determination application file number shall be noted “A”. A rate application file number by a new hospital or a hospital with expanded facilities or new revenue centers shall be noted “N”. The date of receipt of the rate application shall be noted on the docket and on the file. Upon request of the hospital, the Commission shall give the hospital a receipt for the rate application filing, showing the docket, page, and file numbers, and the date of receiving the rate application. The hospital shall file an original and three copies of each rate application and its supporting documents, if any. The Commission may prescribe the format to be used in the submission of rate applications and their supporting documents. In addition, the hospital shall file with each rate application a certificate of service indicating that the application and supporting documents have been mailed or served upon all designated parties to that proceeding and upon the Commission at its offices. A rate application review shall be completed and the recommendation given to the Commission as soon as possible. The recommendation shall include a specification of those areas of costs which the staff believes should be reviewed. When practicable, the recommendation shall also include the amounts challenged by the staff. Any of four actions may be recommended to the Commission. If two or more actions are recommended, the issues and rates to be evaluated in each action shall be set forth clearly. These four actions are as follows: The Commission should hold a public hearing on rates; The Commission should grant tentative approval or modify all or some of the rates and publish notice of an order nisi; The Commission should hold a general hearing on rates; The Commission should deny the application in which case it shall state the grounds for the denial. A copy of the recommendation shall be placed in the file and a copy shall be forwarded to each Commission member, the hospital, and each interested party. The Commission may not call for the effective date of an Order Nisi or call for a public hearing for 30 days after the Commission acts on the staff's recommendation. Before a staff recommendation or public hearing, the staff may hold conferences with hospital representatives and interested parties in an attempt to clarify or resolve potential issues. The Commission may prescribe a process for its consideration of a full rate application, which allows for written submissions in support of an application in lieu of an evidentiary hearing. A hospital that chooses this process for a Commission decision on its full rate application shall be afforded the right to submit to the Commission rebuttal information following any written response to the full rate application filed by Commission staff or designated interested parties. A hospital that chooses this written submission process waives its right to an evidentiary hearing. A hospital that chooses this written submission process does not waive its right to judicial review of a final Commission decision under the Administrative Procedure Act. As an additional alternative to an evidentiary hearing, a hospital may choose to enter into a binding arbitration process as prescribed by the Commission. The Commission shall consider the staff recommendation and, within 20 days of the date of the recommendation, issue its preliminary order adopting or modifying the recommendation, or referring the recommendations back to the staff for further review and subsequent recommendations. Order Nisi. If the Commission issues a preliminary order granting tentative approval of any rates, it shall publish notice of the order nisi and the rates. In addition, the Commission shall forward copies of the order nisi and the rates to the hospital and interested parties. The order nisi shall state: The name and address of the hospital; the names of the designated interested parties; the docket, page, and file numbers of the rate application proceeding and the date the application was filed with the Commission. An enumeration of services and the proposed representative rates to be charged: That the Commission has approved the rates as of a date to be specified, with a provision that the order may be suspended if reasonable cause is shown within 15 days of the date of the Order Nisi. That objections to the tentatively approved rates shall be submitted (in person or by mail) to the Commission in writing; that designated interested parties shall submit copies of their objections, identifying the proceeding and Order Nisi to which objections are made to the hospital, and nine copies to the Commission office; and That the file, which may contain supporting documents from the hospital, the Commission staff recommendation, the Accounting and Reporting reports and the Rate Review System of the hospital, is available at the Commission offices during regular business hours for public inspection. If the Commission issues an order for a public hearing, it shall forward copies of the order and public notice of the hearing to the hospital and the designated interested parties and shall publish a public notice of the hearing. The notice shall state: The name and address of the hospital: the names of the designated interested parties; the docket, page, and file numbers of the rate application proceeding; the date the application was filed with the Commission; and the time, date, and place of the hearing; A description of the issues to be presented at the public hearing; That any person interested in the matter may attend the public hearing; That all persons wishing to present relevant testimony or a statement at the public hearing shall forward copies to the hospital, each designated interested party, and nine copies to the Commission office; that the hospital and members of the public shall forward their testimony at least 8 days before the hearing; that the designated interested parties shall forward their testimony at any time before the close of the first session. Written testimony will not be considered unless the person submitting the testimony makes himself available for cross-examination unless stipulated to the contrary. If the Commission issues an order for a general hearing by the Commission, it shall forward copies of the order and public notice of the hearing to the hospital and the designated interested parties and publish a public notice of the hearing. Testimony shall be in writing and may not be delivered orally, except as set forth in Regulation .14K, of this chapter. Presenting Direct Testimony. Any person who wishes to present direct testimony at the public hearing shall forward copies to the hospital and to every designated interested party, and shall file nine copies at the Commission's office. If the public hearing is the result of a hospital rate application pursuant to Regulation .03, of this chapter, the applicant shall file its testimony at least 20 days before the date of the hearing. The staff of the Commission and members of the public shall file their testimony at least 10 days before the date of the hearing. If the public hearing is the result of a Commission-initiated review of the rates of a hospital pursuant to Regulation .04, of this chapter, the Commission staff shall file its testimony at least 20 days before the date of the hearing. The hospital and members of the public shall file their testimony at least 10 days before the date of the hearing. The designated interested parties shall file their testimony before the close of the first hearing session. The written direct testimony shall set forth the conclusions of the person submitting it and the arguments and facts supporting these conclusions. This testimony shall specifically pertain to the issues set forth in the public notice. Written direct testimony shall be verified either by: Appearing before an officer or other person authorized to administer an oath; or Signing the documents containing the statements required to be under oath and including the following representation: I do solemnly declare and affirm under the penalties of perjury that the facts set forth in the foregoing testimony are true and correct to the best of my knowledge, information and belief. Copies of written direct testimony shall be forwarded by the person submitting them to the hospital and the designated interested parties. All written direct testimony shall pertain solely to the proposed rates and be relevant to that subject. The presiding officer shall separate irrelevant material from the remainder of the record and keep that material apart. Parts of the body of the written direct testimony judged irrelevant by the presiding officer shall be so marked and may not be considered by the Commission in its deliberations. Persons submitting written testimony shall make themselves available for cross-examination and may give redirect and rebuttal testimony, orally or in writing, as directed or permitted by the presiding officer. All testimony at public hearings shall be filed in a timely manner. Requests for hearing postponements shall be made at a reasonable time before the hearing. These requests will only be granted for valid reasons, at the discretion of the Commission. If a hospital requests a postponement of an initial hearing session after the staff has already submitted its testimony, the Commission may require the hospital to file its testimony within the time frame of the original hearing date. The Chairman of the Commission shall preside at the public hearing, which may be called to order when the presiding officer is in attendance. If the Chairman is absent or has been disqualified, the Vice-chairman or another commissioner shall preside. The Commission may direct that a hearing officer preside at the public hearing. In this case, the hearing officer may exercise all powers given to a presiding commissioner in these regulations during all sessions of the public hearing. At the discretion of the Commission, the specific duties of the hearing officer may include the following: Making all rulings as to evidence, testimony, and official notice; Setting the order for the examination and cross-examination of witnesses; Administering oaths and affirmations; Preparing both written and oral summaries of cases heard; Preparing a recommendation for the Commission consisting of a written report with findings of fact and conclusions of law. The presiding officer may adjourn a hearing to a specified time, date, and place. All public hearings shall be recorded and testimony shall be under oath. A transcript of the record of the hearing shall be placed in the file of the proceeding. If the hospital or any other party desires a copy of the transcript, that party shall make arrangements with the stenographer. All direct testimony shall be submitted in writing and in an issue-by-issue format. The hearing shall begin with the examination of the representative of the hospital and any witnesses which the hospital may desire to have testify in its behalf. Whenever practicable, the testimony of witnesses shall proceed on an issue-by-issue basis. The Commission's staff member assigned to the proceeding shall be the next witness to be examined on the issue in question. In a Commission initiated review, the staff member assigned to the proceeding shall be examined before the hospital witness. Representatives of the other interested parties who have submitted written testimony shall be examined in the order set by the presiding officer. The Commission may examine witnesses at any time during the course of the proceeding. Commission staff and representatives of the hospital and interested parties may also examine witnesses. All testimony and examination shall be relevant to the subject of the proposed rates. Redundant and irrelevant testimony and examination shall be prohibited or stricken by the presiding officer. In addition, all interested parties may move the Commission to strike redundant and irrelevant testimony. At the presiding officer's discretion, he may allow direct oral testimony if a person attending the hearing demonstrates good cause for not submitting the testimony in written form before the hearing. Witnesses giving direct oral testimony shall be subject to cross-examination in the same manner as other witnesses. Anyone denied an opportunity to testify may appeal in writing to the full Commission within 7 days from this denial. To preserve his rights on appeal or otherwise, it is not necessary for a party objecting to a Commission ruling or decision to state the grounds of his objection, unless specifically requested to do so by a member of the Commission. At the Commission's reasonable discretion, it may permit the filing of post hearing briefs by the hospital, the Commission staff member or any interested party. Those parties submitting briefs shall file copies within a reasonable time designated by the presiding officer to the hospital, the designated interested parties, the Commission office and to each Commission member. A Commission member shall remove himself from participation in a public hearing as a Commission member if he decides that a conflict of interest may appear to prejudice his evaluation of the issues considered at the public hearing. Challenges to a Commission member's participation in a public hearing as a Commission member shall be considered by the Commission, the decision made by a majority vote, excluding the member objected to. Challenges shall be made by motion, at least 7 days before the public hearing. Except as otherwise provided, all decisions required during the conduct of the public hearing shall be made by the presiding officer. The decision and the opinions of the Commission shall be based solely on the testimony, examination, and evidence presented at the public hearing, on the briefs filed, if any, on the evidence incorporated into the record of the proceeding by reference, on information and data in the record of the proceeding, and on matters as to which the Commission has taken official notice, which matters shall be made known to the parties to the proceedings. The deliberations of the Commission may be held in private executive session. The decision shall be made by a majority of the Commission members attending all sessions of the public hearing, or having read the record of hearings they did not attend. The decision shall be in writing and shall be based on a written majority or unanimous opinion stating the reasons and grounds for the Commission's decision. If a majority of Commissioners who are to render the final decision have not heard the evidence, the decision, if adverse to a party to the proceeding other than the Commission itself, may not be made until a proposal for decision, including findings of fact and conclusions of law, has been served upon the parties, and an opportunity has been afforded to each party adversely affected to file exceptions and present argument to a majority of the Commissioners who are to render the decision, who shall personally consider the whole record or those portions of it as may be cited by the parties. At the discretion of a Commission member (or members) who agrees with the decision reached by the majority of the Commission, but who does not agree with the majority opinion, or any part of it, the Commission member (or members) may file a written concurring opinion. A commission member (or members) who does not agree with the decision or any part of it reached by the majority of the Commission may, at his discretion, file a written dissenting opinion. The Commission's decision and the opinion (or opinions) shall be filed promptly and the Commission's staff then shall forward copies of the Commission's decision and the opinion (or opinions) to the hospital, to the designated interested parties, and to those parties who submitted written direct testimony before the public hearing. The Commission shall then publish: An order approving, modifying, or disapproving the rates under review in the proceeding: A notice that copies of the Commission's decision and the opinion (or opinions) may be obtained by written request to the Commission offices; and A notice that the record of the complete proceeding is open for public inspection at the Commission offices during regular business hours. To obtain general information from the region and community in which a hospital is located, the Commission, at its discretion, may hold a general hearing during the course of any rate proceeding. A general hearing shall be supplementary to other methods of rate review and may not replace them. A general hearing shall be held in the region in which the hospital whose rates are being reviewed is located. The public notice of a general hearing may state: The name and address of the hospital, the designated interested parties, the docket, page, and file numbers of the application, and the time, date, and place of the hearing; A description of the issues to be considered at the general hearing; That any party interested in the matter may attend and present written or oral statements concerning the announced issues; and That presentations may be limited as to time and that the number of spokespersons representing any group or organization may be limited. The general hearing shall be conducted by a hearing officer, any member of the Commission, a senior member of the Commission staff or its legal counsel. Persons attending the general hearing may present written or oral statements concerning the issues and rates set forth in the notice, which statements need not be verified. The presiding officer, within his discretion, may limit the number of spokespersons representing a group or organization and may limit the time allowed for oral statements. The conduct of the general hearing shall be recorded and the transcript shall be placed in the file of the proceedings. Any person may purchase a transcript of the hearing from the stenographer. The presiding officer may ask questions of the spokespersons. Within the discretion of the presiding officer, examination or questions of the spokespersons by other persons may be permitted. A transcript of the oral statements and copies of the written statements shall be placed in the Commission's file of the particular rate review proceeding. The following forms are illustrative of pleadings and papers commonly used by parties in rate review proceedings and should be used wherever possible and, if necessary, adapted to the facts in the proceeding and the needs of the party using the forms: Rate Application. Public Notice of Rate Proceeding. Notice of Public Hearing. Notice of General Hearing: Notice of Orders Nisi. Order Nisi. Orders. Motions. Service. ________________________________________________________________________________________________________ (Signature of party filing pleading) Subpoena Duces Tecum for Rate Review. __________ (date) ________________________________________________________________________________________ Health Services Cost Review Commission Summons for Rate Review. __________ (date) ________________________________________________________________________________________ Health Services Cost Review Commission Summons for Hearing. __________ (date) ________________________________________________________________________________ Health Services Cost Review Commission Subpoena Duces Tecum for Hearing. __________ (date) ________________________________________________________________________________________ Health Services Cost Review Commission All pleadings, motions, and other papers filed in a Commission proceeding shall be typed or legibly written on sheets of bond paper not more than 11 inches long or 8-1/2 inches wide, and each paper shall have a left margin of at least 1 inch and a top margin of at least 1-1/2 inches. All pleadings, motions, and other papers, excluding exhibits appended to the pleadings, shall contain a heading at the top of the first page and, excluding appended exhibits and written direct testimony for a public hearing, a certificate of service at the bottom of the last page. A rate application filed by private messenger at the offices of the Commission shall be deemed to be filed on the date the application is received during normal working hours in the Commission's office. A rate application sent by registered mail shall be deemed to be filed 3 days after the application is placed in the U.S. Postal Service, these days to exclude Saturdays, Sundays, and holidays on which mail is not delivered to the Commission. The rate application's file date shall be entered on the docket of the proceeding. An original and three copies of all other pleadings, documents, testimony, or motions to be considered by the Commission shall be filed at the office of the Commission during regular business hours. All pleadings, documents, testimony, or motions shall contain a certificate of service indicating that the pleading, document, testimony, or motion has been mailed or served upon all designated parties to that proceeding and upon the Commission at its offices. In computing any period of time prescribed by these regulations, by order of the Commission or by any applicable statute, the day of the action or default initiating the designated period of time not be included. The last day of the period so computed is to be included unless it is a day on which the office of the Commission is closed, in which event the period runs until the end of the next day on which the office of the Commission is open. When the period of time allowed is more than 5 days, intermediate Saturdays, Sundays, and legal holidays shall be considered in the same manner as other days, but if the period of time allowed is 5 days or less, intermediate Saturdays, Sundays, and legal holidays may be not counted in computing the period of time. At the discretion of the Executive Director or his designee and, upon reasonable cause being shown by the submitting party, a period of time to submit a document or perform any other act permitted or prescribed by these regulations may be extended for a reasonable period of time. Motions shall be in writing, except when made at a hearing or conference and shall state concisely the question which the Commission is called upon to determine, or the action the movant desires the Commission to take. It shall state all reasons, authorities, and citations in the body of the motion or in a supporting memorandum. A certificate of service, setting forth all parties upon whom a copy of the motion was served, shall be attached to the motion. The following actions shall be taken by motion: Objections to actions of the Commission, or the Commission's staff; motions for clarification or reconsideration may not stay the orders of the Commission; Demands for actions which the movant desires the Commission, or the Commission's staff to take; Showing reasonable cause why an Order Nisi should not become effective; Presenting a proper and justifiable question to the Commission; Objections to the introduction of statements or other evidence by another party during a proceeding; Challenges to members of the Commission; Proposals for stipulations; Answers to prior motions; and All other actions which might be initiated properly or undertaken by a party to a proceeding and which are not otherwise provided for in these regulations. The motion shall be filed with the Commission and a copy shall be served on each affected party. A motion need not be verified unless it is based upon facts not apparent from the record or documents filed in the proceeding. Any affected party may answer an initial motion. The method of considering the motion, whether by executive communication, private hearing, or public hearing shall be determined by the chairman of the Commission. The Commission shall decide upon the question presented or action demanded in the motion in an equitable manner and as soon as practicable. Except when a motion is made at a conference or a hearing, the order granting or denying the motion shall be in writing and shall be entered on the record of the proceeding and copies of the order shall be served upon the moving party and all affected parties. The decision expressed in the order shall be decided pursuant to these regulations, if provision is made. If no provision is made, the motion shall be decided by a majority of the Commission. However, motions made in the course of a private conference or at a public hearing shall be decided by the presiding officer or a majority of the Commission attending the session of the conference or hearing at which the motion was made, as provided elsewhere in these regulations. Motions made in the course of a general hearing shall be decided by the hearing officer. At any time, the Commission may issue subpoenas directing a designated person to do the following: Appear to testify at a hearing or private pre-hearing conference conducted by the Commission: Appear at a specified time and date at the Commission offices or any designated place within the State, and, under oath or otherwise, give testimony and answer questions of the Commission or its authorized representatives; or Produce documents, reports, or records of a particular activity for a specific period of time if he has custody of or access to the documents, reports, or records; the records may be in any reasonable form; the production shall be made at a specified time, date, and place. A subpoena shall be in whatever form is prescribed by the Commission and shall include: The name, title, if any, and address of the person upon whom it is to be served and the address at which it is to be served; The name(s), title(s), or position(s) of the witness(es) who shall appear and the time, date and place of their appearance. A reasonable specification of the documents, reports and/or records, if any, to be produced at the designated time, date and place. Subpoenas shall be served at least 7 days before any public hearing or private or pre-hearing conference or executive session of the Commission at which the witness or witnesses are directed to appear, and shall be served at least 3 days before a private appointment. Subpoenas shall be served in person by a person designated by the executive director or, at his discretion, by registered or certified mail, return receipt requested. A signed return of the service or the return receipt shall be entered in the file and noted on the docket of the proceeding. A witness or a party with whom he is associated or affiliated may move to quash or modify the subpoena directed to him at any time before the date set for his appearance by filing with the Commission a motion to quash or modify the subpoena as provided in that section which pertains to motions in general. Failure to appear or to produce documents in accordance with a subpoena shall subject the witness or the party with which he is affiliated or associated to a finding of contempt by the Commission and other penalties provided by law or these regulations. The effective date of rates applied for in a rate application shall be 30 days from the date of the filing of the rate application with the Commission and shall be specified in the rate application. The Commission's staff may recommend the suspension of the effective date of the rates under review. At any time during a rate review, the Commission may order a suspension of the effective date of the rates under review, within the time specifications of Health-General Article, §19-219, Annotated Code of Maryland, and shall state the grounds for its action. The presiding officer at a public hearing or general hearing shall make all rulings as to evidence, testimony, and official notice and he may call on the legal counsel of the Commission for guidance in his rulings. All evidence and testimony shall be relevant and pertain solely to the issues being considered in a particular proceeding. Redundant evidence or testimony may not be permitted at public or general hearings or in the records of proceedings. Non-expert opinion testimony may be considered at a hearing and documentary opinion evidence may be entered in the record of a proceeding if the testimony or evidence is based on facts and matters admissible into evidence and the facts and matters are within the personal knowledge of the submitter of the document. Qualification as an expert shall be within the discretion of the presiding officer of the public or general hearing at which the proposed expert may proffer testimony or evidence or, if evidence is proffered at a time other than at a public hearing, within the discretion of the chairman of the Commission considering the proceeding. The expert qualification need not be based upon academic degrees or learning; reasonably extensive practical experience with the subject may be sufficient for an expert qualification. Subject to the provisions of these regulations, legal rules of evidence shall be followed as far as practicable at public and general hearings. Reliable and probative documents previously filed with or compiled by the Commission or its staff or consultants that are relevant to issues being considered by the Commission may be incorporated by reference into the record of a proceeding by the Commission or, by leave of the presiding officer, by a party to the proceeding. In the course of a proceeding, the Commission may take official notice of facts and matters in the same manner as the courts of the State take judicial notice of facts and matters and, additionally, may take notice, without meeting formal evidentiary rules, of general, technical, or scientific facts within the specialized knowledge of a member of the Commission. However, any party to the proceeding is entitled, on timely request, to an opportunity to show that the Commission should not take official notice of specific facts and matters or that the fact or matter to be officially noticed is inapplicable to the proceeding or is incorrect or misunderstood by the Commission. In reviewing a hospital's rate structure, the Commission may consider or take official notice of any public document, including, but not limited to, any filing made with the Maryland Health Resources Planning Commission relative to a Certificate of Need application including all projections of volumes, revenues, rates, and feasibility studies, as well as any public document concerning the financing of a project approved pursuant to a Certificate of Need. Definitions. In this regulation, the following terms have the meanings indicated. Terms Defined. “Debt collector” has the meaning stated in COMAR 10.37.13.01. “Hospital” means a “facility” as defined in Health-General Article, §19- 301, Annotated Code of Maryland. “Income-based payment plan” means a payment plan based on the patient’s household income as set forth in COMAR 10.37.13.05. “Payment plan” has the meaning stated in COMAR 10.37.13.01. A third-party payer may obtain a discount in rates established by the Commission if it provides current financing monies in accordance with the following terms. A third-party payer that provides current financing equal to the average amount of outstanding charges for bills from the end of each regular billing period and for discharged patients shall be entitled to a 2-percent discount. For purposes of this regulation, a regular billing period shall be based on a 30-day billing cycle. The current financing provided in here corresponds to a third party's paying on discharge. A third-party payer that provides current financing equal to the average amount of outstanding charges for discharged patients plus the average daily charges times the average length of stay, shall be entitled to a 2.25-percent discount. The current financing provided to hospitals corresponds to a third party's paying on admission. Outstanding charges shall be calculated by an amount equal to the hospital’s current average daily payment by the payer, multiplied by the hospital’s and third party payer’s processing and payment time. The precise calculation shall be made in accordance with the guidelines specified by Commission staff. Upon request from an applicant, the Commission may approve an alternative method of calculating current financing monies. The third-party payer shall adjust the current financing advance to reflect Commission rate orders and changes in volume associated with the particular payer and hospital. This adjustment shall be made within 45 days of a rate order or at such other time as circumstances warrant. In the absence of a rate order, the adjustment shall be made at least annually. The third-party payer shall promptly provide the Commission with a verified record of the detailed calculation of the current financing and of each recalculated balance as adjustments are made. The detailed calculations shall become a part of the public record. The Commission may, at any time, evaluate the amount of current financing monies provided to a hospital to assure that it meets the discount of requirements specified in §B of this regulation. If the Commission finds that the amount of current financing is inconsistent with the requirements of §B of this regulation, the Commission may, at its sole discretion, require an adjustment to the working capital advance or to the discount. Discounts. A payer or self-paying patient, who does not provide current financing under §B of this regulation, shall receive a 2-percent discount if payment is made at the earlier of the end of each regular billing period or upon discharge from the hospital. Payment within 30 days of the earlier of the end of each regular billing period or discharge entitles a payer or self-pay patient to a 1-percent discount. For those payers not subject to Insurance Article, §15-1005, Annotated Code of Maryland, after 60 days from the date of the earlier of the end of each regular billing period or discharge, interest or late payment charges may accrue on any unpaid charges at a simple rate of 1 percent per month. The interest or late payment charges may be added to the charge on the 61st day after the date of the earlier of the end of each regular billing period or discharge and every 30 days after that. For patients that have entered into a hospital income-based payment plan under COMAR 10.37.13.05, the interest rate shall be established in accordance with the Guidelines set forth in COMAR 10.37.13.05. Hospital Billing Responsibilities. A patient shall be given a bill for services at the earlier of the end of each regular billing period or upon discharge or dismissal, when dismissal for outpatients is analogous to discharge for inpatients. This bill shall cover substantially all care rendered and should, except for some last day ancillary services and excepting arithmetic errors, represent the full charge for the patient's care. A notice shall be posted prominently at the billing office of the hospital clearly notifying all patients of the availability of the discounts referred to in §D of this regulation. The bill and the notice shall state that the patient shall receive a 2-percent discount by paying upon discharge or a 1-percent discount by paying within 30 days of discharge. GME Discounts. In those instances where a teaching hospital is reimbursed separately for the costs associated with the provision of graduate medical education (GME), the Commission shall calculate the percentage of the hospital's rates that these GME payments represent and provide notice of the amounts that may be credited toward the payment for services rendered. At all times, total payment received by the teaching hospital shall be in accordance with Commission-approved rates. The Commission shall determine and assess those funds necessary to operate and administer the MHIP. The Commission shall adjust hospital rates to implement the revenue neutral assessment. The Commission shall assess each hospital up to 1 percent of its net patient revenue to operate and administer the MHIP. There shall be no MHIP assessment for Fiscal Year 2016. Beginning on September 5, 2003, each hospital whose rates have been approved by the Commission shall remit monthly, by the 5th of each month, 1/12 of its total share of the annual funding assessment determined by the Commission to be owed by the hospital to the Maryland Health Insurance Plan Fund as established under Insurance Article, Title 14, Subtitle 5, Annotated Code of Maryland. A hospital that fails to remit its funding assessment due in a timely manner may be subject to an annualized interest charge of 3 percentage points above the most recent average prime rate of interest, as published in the “Money Rates” section of The Wall Street Journal, on the unpaid balance. In addition, the Commission may impose penalties of up to 5 percent of the amount of any underpayment made by the hospital. Beginning July 1, 2008, the Commission shall assess annually a uniform, broad-based, and reasonable amount in hospital rates to reflect the aggregate reduction in hospital uncompensated care resulting from the expansion of health care coverage under Ch. 7, Acts of 2007 Special Session. Given the prospective nature of the rate system, the Commission shall ensure that the assessment amount does not exceed the savings projected in averted hospital uncompensated care from the health care coverage expansion. The Commission shall notify hospitals annually of the amount to be assessed by July 1 of each year, to be effective July 1. Beginning September 2008, on or before the 5th business day of each month, each hospital assessed in accordance with Health-General Article §19-214, Annotated Code of Maryland, and the provisions of this regulation shall make payment into the Health Care Coverage Fund established under Health-General Article, §15-701, Annotated Code of Maryland. A hospital that fails to remit its monthly funding assessment in a timely manner may be subject to an annualized interest charge of 3 percent the most recent average prime rate of interest, as published in the “Money Rates” section of the Wall Street Journal, on the unpaid balance. In addition, the Commission may impose penalties of up to 5 percent of the amount of any underpayment made by the hospital. Designated interested parties for a specific rate review proceeding may include: Those community oriented groups which the Commission determines have a significant interest in the hospital and its rate application; Those third-party payors or their representatives who have been designated by the Commission as interested parties for this proceeding; The hospital whose rates are being reviewed; Maryland Health and Higher Educational Facilities Authority for rate review proceedings concerning hospitals with capital financing through the Authority. Group Hospitalization, Incorporated, for rate review proceedings concerning hospitals with which it has contractual relations; and Legal Aid Bureau of Baltimore City. Designated interested parties for all rate applications are: Provider Reimbursement Department of Blue Cross of Maryland, Inc.; Medical Care Programs Administration of the Maryland Department of Health (Medicaid); Division of Provider Reimbursement and Accounting Policy, Bureau of Health Insurance, Social Security Administration, Department of Health, Education and Welfare of the United States (Medicare); and Health Insurance Association of America. A hospital or any other party in a rate review proceeding may be represented by legal counsel at any or all times during the proceeding, but there is no requirement that parties have legal counsel. Any party to a proceeding may challenge the ability of any member of the Commission to consider the rates or issues in that proceeding. Excepting private conferences, this challenge shall be made during the proceeding before its first hearing. Challenges may not be permitted after the first hearing, except in extraordinary circumstances. A challenge shall be verified in writing, specifying the member of the Commission and shall set forth all its reasons. The challenge shall be filed with the Commission and entered upon the record of the proceeding. A copy of the challenge shall be forwarded to the challenged member immediately after it is filed, and he may make whatever response he deems proper and necessary. The challenge shall be denied or allowed by a majority of the Commission, excluding the challenged member. The order based on the decision shall be filed with the Commission, entered in the record of the proceeding and served on the challenged member and the challenging party. If a challenge to a Commission member is allowed, he immediately shall cease all participation in the proceeding in question as a Commission member. The allowance of a challenge to a member of the Commission may not, in itself, disqualify him from serving as a Commission member in other matters and proceedings. When two or more rate proceedings involve common questions of fact, the Commission, upon a majority vote of its members, may order that the common questions of fact be decided in a consolidated proceeding. In proceedings initiated by a regular, temporary, or new hospital rate application, the burden of proof of the reasonableness, equity, and lack of undue discrimination of the proposed rates shall rest with the hospital. In proceedings initiated by an application for an alternative method of rate determination, the burden of proof of the applicability of the alternative method of rate review to the hospital shall rest with the hospital. In proceedings initiated by an order for Commission review of established rates, the burden of proof of the reasonableness, equity, and lack of undue discrimination of the established rates under review shall rest with the hospital. If any section or provision of these regulations is declared unconstitutional or void by any court of competent jurisdiction, or its applicability to any person or circumstances is held invalid, the constitutionality or validity of the remainder of the regulations and the applicability to other persons and circumstances are not affected, and to this end, the sections and provisions of these regulations are declared to be severable. Any interested party may file with the Commission a petition for the promulgation, amendment, or repeal of a regulation designed to implement, interpret, or prescribe law, policy, organization, procedure, or practice requirements of the Commission. The petition shall set forth: The interest of the petitioner and the nature of the relief desired; Any facts, views, arguments, and data deemed relevant by the petitioner; Verification under oath by the party or by a duly authorized officer or agent of the party, whose address and title shall be stated. If the petition is for the promulgation of a regulation, a copy of the proposed regulation shall be attached. If the petition is for the amendment of a regulation, a copy of the amended regulation shall be attached with new matters underlined and matters to be deleted bracketed. In addition to and accompanying the original of the petition filed with the Commission, there shall be 12 copies for use of the Commission and other interested parties. The Commission shall consider the petition as well as all comments relating to it by interested parties. Within 30 days from the filing of the petition, the Commission shall render a decision: Denying the petition and stating the reasons therefor; or Submitting the proposed action to the Maryland Register for notice to, and comments by, all interested parties. An interested person may file with the Commission a petition for a declaratory ruling with respect to the manner in which the Commission would apply a statute that the Commission enforces, a regulation of the Commission, or an order of the Commission, to a person or property on the facts set forth in the petition. The petition for a declaratory ruling shall be filed in writing and shall contain a statement describing in detail the interest of the petitioner in making the request, the issues involved, a statement of the facts, a listing of documents or statements, or both, to be considered, and a sworn statement by the petitioner that the facts contained there are true to the best of the person's knowledge and belief. Sixty days from the receipt of the petition the Commission shall inform the petitioner whether the petition will be granted. If the petition is not granted the Commission shall inform the petitioner in writing of the reasons for the denial. If the petition is granted, the Commission shall inform the petitioner when to expect the declaratory ruling. Consideration. The petition shall be granted whenever the Commission deems issuing a declaratory ruling advisable under the circumstances. In rendering its declaratory ruling, the Commission: Shall consider all the materials submitted with the petition; or May, in its discretion: Consult individuals or materials outside the corners of the petition; or Require argument of the question or permit the introduction of evidence. Disposition. A declaratory ruling issued shall be in writing, stating the: Issue; Conclusion; Facts upon which the conclusion was based; and Sources relied upon. A declaratory relief issued by the Commission shall plainly state on its face that it is a declaratory ruling pursuant to this regulation. A written answer from the Commission to an inquiry may not be construed as a declaratory ruling unless made in conformity with these regulations. Publication and Inspection. The Commission: Shall keep a record of each declaratory ruling issued and index all declaratory rulings issued by reference to statute or statutes or regulation or regulations involved. May publish a declaratory ruling of general interest subject to the mandates of the Public Information Act, State Government Article, §10-601 et seq., Annotated Code of Maryland, and allow inspection of the declaratory rulings subject to the Public Information Act. Denial of a Petition for Declaratory Ruling. A petition may be denied if the: Request contains incomplete information upon which to base an informed declaratory ruling; Commission concludes that a declaratory ruling cannot reasonably be given on the matter; Matter is adequately covered by a prior regulation, declaratory ruling, decision, or legal opinion; or Commission concludes that a declaratory ruling would not be in the public interest. Effect. A declaratory ruling shall be binding upon the Commission and the petitioner on the statement of facts covered in the declaratory ruling and set forth in the petition. After notice and an opportunity to reply, a declaratory ruling may be reconsidered, amended, altered, or revoked by the Commission. Appeal. A declaratory ruling is subject to review as provided in State Government Article, §10-305, Annotated Code of Maryland. Health-General Article, §§15-601 et seq. and 19-201, 19-207, 19-210—19-214, 19-214.1, 19-214.2, 19-214.3, 19-216—19-220, and 19-222; Insurance Article, §§14-501, 14-502, and 14-504; State Government Article, §10-304(b); Annotated Code of Maryland Effective date: November 7, 1974 (1:4 Md. R. 177) Regulation .16 amended effective August 20, 1975 (2:18 Md. R. 1234) Regulation .100 adopted effective December 10, 1975 (2:28 Md. R. 1680) Chapter revised effective October 27, 1976 (3:22 Md. R. 1250) Regulation .01 amended effective November 8, 2004 (31:22 Md. R. 1595) Regulation .01I, J adopted effective January 8, 1990 (16:26 Md. R. 2794) Regulation .01K adopted effective May 12, 2003 (30:9 Md. R. 615) Regulation .01-1 adopted effective October 5, 1998 (25:20 Md. R. 1531) Regulation .02B amended effective December 14, 1987 (14:25 Md. R. 2660) Regulation .03 amended as an emergency provision effective June 15, 1998 (25:14 Md. R. 1127); emergency status expired December 15, 1998 Regulation .03 amended effective August 5, 2002 (29:15 Md. R. 1142); January 15, 2018 (45:1 Md. R. 14) Regulation .03A amended as an emergency provision effective July 1, 2000 (27:17 Md. R. 1616); emergency status extended at 27:26 Md. R. 2356; emergency status extended at 28:7 Md. R. 687; emergency status expired July 1, 2001 Regulation .03A amended effective November 7, 2005 (32:22 Md. R. 1756); October 8, 2007 (34:20 Md. R. 1740); April 11, 2016 (43:7 Md. R. 450); January 16, 2017 (44:1 Md. R. 12); December 13, 2021 (48:25 Md. R. 1080) Regulation .03A amended as an emergency provision effective November 3, 2022 (49:25 Md. R. 1048); emergency provision expired May 1, 2023 Regulation .03A amended effective May 1, 2023 (50:8 Md. R. 338) Regulation .03B amended effective September 1, 2003 (30:17 Md. R. 1203); March 15, 2004 (31:5 Md. R. 449) Regulation .03C adopted effective November 19, 1984 (11:23 Md. R. 1993) Regulation .03C amended effective October 3, 1988 (15:20 Md. R. 2334) Regulation .03D adopted effective January 8, 1990 (16:26 Md. R. 2794) Regulation .03D recodified as .03C effective August 5, 2002 (29:15 Md. R. 1142) Regulation .03D adopted as an emergency provision effective January 1, 2004 (31:4 Md. R. 313); adopted permanently effective May 10, 2004 (31:9 Md. R. 713) Regulation .03D amended as an emergency provision effective July 1, 2009 (36:15 Md. R. 1163); amended permanently effective October 5, 2009 (36:20 Md. R. 1529) Regulation .03-1 adopted effective November 8, 2004 (31:22 Md. R. 1595) Regulation .03-1A amended effective January 15, 2018 (45:1 Md. R. 14) Regulation .03-1B amended effective May 8, 2006 (33:9 Md. R. 796); April 11, 2016 (43:7 Md. R. 450) Regulation .04 amended effective June 15, 1979 (6:12 Md. R. 1050) Regulation .04C adopted effective May 1, 2023 (50:8 Md. R. 338) Regulation .04-1 adopted as an emergency provision effective October 8, 1998 (25:22 Md. R. 1650); adopted permanently effective February 8, 1999 (26:3 Md. R. 175) Regulation .04-1 amended as an emergency provision effective May 21, 2001 (28:13 Md. R. 1214); amended permanently effective September 3, 2001 (28:17 Md. R. 1557) Regulation .04-1 amended effective January 15, 2018 (45:1 Md. R. 14) Regulation .04-2 adopted effective November 13, 2000 (27:22 Md. R. 2060) Regulation .04-2 amended effective April 30, 2001 (28:8 Md. R. 760); January 15, 2018 (45:1 Md. R. 14) Regulation .04-2A, C amended effective January 12, 2009 (36:1 Md. R. 22) Regulation .04-2C amended effective October 9, 2006 (33:20 Md. R. 1617) Regulation .04-3 adopted effective November 13, 2000 (27:22 Md. R. 2060) Regulation .04-3 amended effective April 30, 2001 (28:8 Md. R. 760); January 15, 2018 (45:1 Md. R. 14) Regulation .05 amended as an emergency provision effective July 1, 2000 (27:17 Md. R. 1617); amended permanently effective November 13, 2000 (27:22 Md. R. 2060) Regulation .05 amended effective September 3, 2001 (28:17 Md. R. 1557) Regulation .05F amended as an emergency provision effective November 3, 2022 (49:25 Md. R. 1048); emergency provision expired May 1, 2023 Regulation .05F amended effective May 1, 2023 (50:8 Md. R. 338) Regulation .06E adopted effective August 28, 1995 (22:17 Md. R. 1318) Regulation .06E amended effective September 9, 1996 (23:18 Md. R. 1317); November 4, 1996 (23:22 Md. R. 1497); February 9, 1998 (25:3 Md. R. 146) Regulation .06E recodified to .06F and new .06E adopted effective October 5, 1998 (25:20 Md. R. 1531) Regulation .06F amended effective March 4, 2013 (40:4 Md. R. 346) Regulation .06G adopted effective October 9, 2006 (33:20 Md. R. 1617) Regulation .07 amended effective August 31, 1977 (4:18 Md. R. 1398) Regulation .07-1 adopted effective September 10, 2007 (34:18 Md. R. 1580) Regulation .07-1A amended effective December 13, 2021 (48:25 Md. R. 1080) Regulation .07-1C amended effective December 21, 2015 (42:25 Md. R. 1544); May 9, 2016 (43:9 Md. R. 530) Regulation .07-1E amended effective May 14, 2012 (39:9 Md. R. 612) Regulation .07-1K, L adopted effective December 13, 2021 (48:25 Md. R. 1080) Regulation .07-2 adopted effective January 16, 2017 (44:1 Md. R. 12) Regulation .10C amended effective April 9, 1984 (11:7 Md. R. 626); March 8, 1999 (26:5 Md. R. 391); December 21, 2015 (42:25 Md. R. 1544) Regulations .11C and .12B amended effective May 29, 1981 (8:11 Md. R. 975) Regulation .11G adopted effective January 15, 2018 (45:1 Md. R. 14) Regulation .13B amended effective September 19, 1980 (7:19 Md. R. 1806) Regulation .13H adopted effective July 28, 1978 (5:15 Md. R. 1190) (originally codified as Regulation .12G) Regulation .14I amended effective December 12, 2002 (29:24 Md. R. 1919) Regulation .20 amended effective April 9, 1984 (11:7 Md. R. 626); March 8, 1999 (26:5 Md. R. 391) Regulation .23 amended effective May 11, 1977 (4:10 Md. R. 767) Regulation .25I adopted effective May 9, 1983 (10:9 Md. R. 791) Regulation .26 amended as an emergency provision effective June 19, 2009 (36:15 Md. R. 1163); amended permanently effective October 5, 2009 (36:20 Md. R. 1530) Regulation .26 amended effective November 15, 2010 (37:23 Md. R. 1611); December 11, 2025 (52:24 Md. R. 1198) Regulation .26A amended effective July 1, 1988 (15:13 Md. R. 1555); April 3, 1989 (16:6 Md. R. 728); November 26, 1990 (17:23 Md. R. 2732); March 30, 1992 (19:6 Md. R. 674); June 7, 1993 (20:11 Md. R. 913); July 5, 1993 (20:13 Md. R. 1049); August 1, 1994 (21:15 Md. R. 1306) Regulation .26A amended as an emergency provision effective June 1, 1996 (23:13 Md. R. 938); emergency status expired November 13, 1996 Regulation .26A amended December 30, 1996 (23:26 Md. R. 1860) Regulation .26A amended as an emergency provision effective November 24, 1997 (24:26 Md. R. 1752); emergency status extended to August 31, 1998 (25:12 Md. R. 943); emergency status extended to October 31, 1998 (25:18 Md. R. 1431) Regulation .26A amended October 5, 1998 (25:20 Md. R. 1531) Regulation .26A amended as an emergency provision effective February 25, 1999 (26:6 Md. R. 480); amended permanently effective June 28, 1999 (26:13 Md. R. 1020) Regulation .26A amended as an emergency provision effective June 26, 2000 (27:15 Md. R. 1397); amended permanently effective November 13, 2000 (27:22 Md. R. 2060) Regulation .26A amended as an emergency provision effective December 6, 2000 (28:3 Md. R. 203); amended permanently effective April 30, 2001 (28:8 Md. R. 760) Regulation .26A amended effective October 29, 2001 (28:21 Md. R. 1856); May 13, 2002 (29:9 Md. R. 745) Regulation .26A repealed effective September 1, 2003 (30:17 Md. R. 1203) Regulation .26A amended effective November 15, 2010 (37:23 Md. R. 1611); August 6, 2012 (39:15 Md. R. 963); May 6, 2019 (46:9 Md. R. 445); April 5, 2021 (48:7 Md. R. 259) Regulation .26A-2 amended effective December 10, 2012 (39:24 Md. R. 1577); April 5, 2021 (48:7 Md. R. 259) Regulation .26A-3 adopted effective April 5, 2021 (48:7 Md. R. 259) Regulation .26B amended effective October 3, 1988 (15:20 Md. R. 2334); May 29, 1989 (16:10 Md. R. 1109); May 14, 1990 (17:9 Md. R. 1092); August 1, 1994 (21:15 Md. R. 1306); March 11, 1996 (23:5 Md. R. 380); September 30, 2002 (29:19 Md. R. 1524); April 10, 2006 (33:7 Md. R. 673); April 5, 2010 (37:7 Md. R. 572); August 4, 2014 (41:15 Md. R. 891) Regulation .26C adopted as an emergency provision effective April 7, 1998 (25:9 Md. R. 677); emergency status expired July 22, 1998; adopted permanently effective September 7, 1998 (25:18 Md. R. 1435) Regulation .26-1 adopted effective May 12, 2003 (30:9 Md. R. 615) Regulation .26-1 amended as an emergency provision effective June 12, 2008 (35:14 Md. R. 1244); amended permanently effective October 6, 2008 (35:20 Md. R. 1775) Regulation .26-1B amended as an emergency provision effective March 21, 2014 (41:8 Md. R. 468); emergency status extended to August 1, 2014 (41:15 Md. R. 888); amended permanently effective July 7, 2014 (41:13 Md. R. 753) Regulation .26-1 amended as an emergency provision effective July 1, 2015 (42:16 Md. R. 1053); amended permanently effective November 9, 2015 (42:22 Md. R. 1378) Regulation .26-2 adopted effective March 9, 2009 (36:5 Md. R. 423) Regulation .27A amended effective February 18, 2002 (29:3 Md. R. 221) Regulation .100 recodified as Regulation .33 Regulation .34 adopted effective August 1, 1987 (14:15 Md. R. 1660) Regulation .35 adopted effective August 1, 1987 (14:15 Md. R. 1660) Regulation .36 adopted effective August 1, 1987 (14:15 Md. R. 1660) “Commission” means the Health Services Cost Review Commission created by Chapter 627, Sec. 1, 1971 Laws of Maryland, and Health-General Article, § 19-202, Annotated Code of Maryland. All related institutions shall immediately submit to the Commission a list of their current charges to patients. All related institutions shall immediately submit to the Commission their current interim Medicaid per diem rate, if any, and any supplementary charges to Medicaid patients. All changes shall be reported promptly to the Commission until the institution's Medicaid per diem rate is approved by the Commission. Final per diem rates shall be filed with the Commission during regular business hours. All information filed pursuant to Sec. A and B, above shall be open to public inspection and shall be available for examination at the offices of the Commission during regular business hours. Increases in the charges to be applied to non-Medicaid patients to be admitted to the related institution shall be submitted to the Commission at least 30 days before their implementation. All information filed pursuant to this section shall be open to public inspection and shall be available for examination at the offices of the Commission during regular business hours. Beginning with the second year of the Commission rate-approval for Medicaid, increases in the charges to be applied to patients who have already been admitted to a related institution may not exceed the allowed percentage increase of Medicaid rates in that institution without Commission approval. Before the second year of Commission rate-approval for Medicaid, the rate of increase by related institutions may not exceed the Commission approved general inflation increase for Medicaid patients without Commission approval. The approved inflation increase in the Medicaid rate shall accumulate and may be adjusted by the Commission for cost changes unique to an individual related institution. Patients Once Admitted. All charges to patients who have once been admitted to a related institution are subject to Sec. E and F, above. Patients “once admitted” include: Patients going from a related institution to a hospital and back to the related institution; Patients leaving a related institution temporarily on a physician-approved leave and then returning to the related institution; Anyone readmitted to the same institution within a 2-week time period. Patients who are for valid medical reasons transferred to a different level of care within a related institution may not be charged prospectively more than that which they could be charged if originally admitted to that new level. Sections E--H shall be effective only if Medicaid is paying Commission-approved rates in any related institution. Health-General Article, § 19-219, Annotated Code of Maryland Effective date: May 11, 1977 (4:10 Md. R. 768) In this chapter, the following terms have the meanings indicated. Terms Defined. “Cross-subsidization” means the practice of charging a purchaser or class of purchaser more than the cost of care for a service with the result that another purchaser or class of purchaser is charged less than the cost of care for the same service. “Discount” means a reduction to Commission-approved rates. “Fixed-price contract” means an agreement or contract, written or oral, that sets forth a preestablished price for the provision of hospital services, or for the provision of hospital services in combination with physician or other services, that differs from Commission-approved rates. Related Entity. “Related entity” means an entity that is entering into at-risk arrangements for hospital-provided services and which is either subject to the exercise of control or significant influence by the management or operating policies of a hospital or exercises control over the management or operating policies of a hospital. In either event, one of the entities is, or may be, prevented from fully pursuing its own separate interests by virtue of its relationship with the other entity. Examples of “related entity” transactions include transactions between: A parent and its subsidiaries; Subsidiaries of a common parent; An entity and trusts for the benefit of employees that are managed by or under the trusteeship of the entities' management; An entity and its principal owners, management, or members of their immediate families; Affiliates (an entity that, directly or indirectly through one or more intermediaries, controls, is controlled by, or is under common control of another entity); An entity and a joint venture whose participants include the entity or a related entity; and Two entities, both of which are related, directly or indirectly, to a common entity. In order to assure purchasers of health care hospital services that rates are set equitably among all purchasers of services without undue discrimination, a hospital may not intentionally or otherwise engage in cross-subsidization without approval by the Commission. A hospital may grant a discount only as provided for in COMAR 10.37.10.26. Without the prior approval of the Commission, neither a hospital, a related entity, nor any entity or person acting on behalf of or in concert with a hospital shall enter into a fixed-price contract, or knowingly participate in or receive the benefit of any arrangement, directly or indirectly, pertaining to the delivery of hospital services. A hospital that has knowledge of such an arrangement shall promptly notify the Commission in accordance with this section in order that the Commission may determine whether the arrangement constitutes an unapproved discount. In order to obtain prior approval of the Commission, the hospital shall file a written application in accordance with COMAR 10.37.10.06. The filing of this application constitutes the filing of a required report under Commission law and regulation. Failure to file an application before the date on which a fixed-price contract is entered into, or the hospital or related entity knowingly participates in or receives benefit of such an arrangement, may subject the organization or organizations to fines up to $1,000 per day for each day the arrangement exists without prior approval. Factors to Consider When Reviewing a Proposed Arrangement. In reviewing a proposed arrangement under this regulation, the Commission shall consider the following factors: Whether the hospital is charging Commission-approved rates and whether payment for hospital services provided is made on the basis of Commission-approved rates; Whether any proposed deviation from Commission-approved rates is cost justified and does not result in any form of cross-subsidization; Whether payment at Commission-approved rates is made by an entity not related to the hospital; The term of the agreement and the termination provisions; The items or services to be furnished under the proposed agreement, including but not limited to hospital services, and the methodology for computing the payment for these services; and The proposed sources of funding for the arrangement, including the source of funds to cover any anticipated or unexpected losses under the arrangement. An agreement may not be reviewed for reasonableness unless the agreement is reduced to writing and specifies in advance the items or services to be furnished as well as the fixed price or methodology used to compute payment. The risk of substantial loss associated with any arrangement may not be borne by the hospital, either directly or indirectly. For a period beginning with the effective date of this regulation and for a period of 6 months after that, the Commission shall offer an amnesty period. Any hospital which brings to the Commission's attention within the 6-month amnesty period any arrangement to which it is, directly or indirectly, a party shall have any price or compliance penalties which might otherwise have been imposed against it in connection with the arrangement, as set forth in Regulation .03 of this chapter, waived. The waiver shall expire at the later of the end of the 6-month amnesty period or the consideration of the Commission of the approval of the arrangement. The Commission may impose penalties of up to $1,000 per day, which shall be instead of the $100 per day penalty for failing to file reports as set forth in COMAR 10.37.01.03N, for a required report submitted by a hospital that includes information which has the effect of violating Regulation .02 of this chapter. The report shall be considered substantially inaccurate and untimely filed. A hospital that violates the provisions of Regulation .02 of this chapter shall, in addition to any penalties imposed under §A of this regulation, be subject to the overcharge and undercharge penalties contained in COMAR 10.37.03.05, which shall be applied to the difference between what was actually charged by the hospital and what the hospital would have been required to charge under a valid Commission rate order based on accurate information filed. In addition, the Commission may revoke any discount previously granted under COMAR 10.37.10.26 to a third party that participates in an arrangement determined by the Commission to constitute an unapproved discount or otherwise violates the provisions of Regulation .02 of this chapter. Health-General Article, §§19-207, 19-210, 19-212, and 19-216, Annotated Code of Maryland Effective date: January 2, 1983 (9:26 Md. R. 2572) Regulation .01 repealed and new Regulations .01 — .03 adopted effective February 17, 1992 (19:3 Md. R. 305) Regulation .01 amended effective June 7, 1993 (20:11 Md. R. 913); December 2, 1996 (23:24 Md. R. 1683) Regulation .02 amended effective June 7, 1993 (20:11 Md. R. 913); December 2, 1996 (23:24 Md. R. 1683) Regulation .02B amended effective March 10, 1997 (24:5 Md. R. 412); July 28, 1997 (24:15 Md. R. 1062); March 4, 2013 (40:4 Md. R. 347) Regulation .03A amended effective March 4, 2013 (40:4 Md. R. 347) Regulation .03B amended effective June 7, 1993 (20:11 Md. R. 913) In this chapter, the following terms have the meanings indicated. Terms Defined. “Credit and collection policy” means a hospital’s policy on the collection of medical debt. Debt Collector. “Debt collector” means a person who engages directly or indirectly in the business of: Collecting for, or soliciting from another, medical debt; Giving, selling, attempting to give or sell to another, or using, for collection of medical debt, a series or system of forms or letters that indicates directly or indirectly that a person other than the hospital is asserting the medical debt; or Employing the services of an individual or business to solicit or sell a collection system to be used for collection of medical debt. “Debt collector” includes a “collection agency” as defined in Business Regulation Article, §7-101, Annotated Code of Maryland. “Financial hardship” means medical debt, incurred by a family over a 12-month period, that exceeds 25 percent of family income. “Hospital” has the meaning stated in Health-General Article, §19- 301(f), Annotated Code of Maryland. Hospital Services. “Hospital services” means: Inpatient hospital services as enumerated in 42 C.F.R. §409.10, as amended; Emergency services, including services provided at a freestanding medical facility licensed under Health Occupations Article, Title 19, Subtitle 3A, Annotated Code of Maryland Outpatient services provided at a hospital as defined in COMAR 10.37.10.07-2; Outpatient services, as specified by the Commission in COMAR 10.37.10.07-2, provided at a freestanding medical facility licensed under Health-General Article, Title 19, Subtitle 3A, Health-General Article, Annotated Code of Maryland that has received a certificate of need under Health-General Article, §19–120(o)(1), Annotated Code of Maryland, or an exemption from obtaining a certificate of need under Health-General Article, §19–120(o)(3), Annotated Code of Maryland; and Identified physician services for which a facility has Commission–approved rates on June 30, 1985. “Hospital services” includes a hospital outpatient service: Of a hospital that, on or before June 1, 2015, is under a merged asset hospital system; That is designated as a part of another hospital under the same merged asset hospital system to make it possible for the hospital outpatient service to participate in the 340B Program under the federal Public Health Service Act; and That complies with all federal requirements for the 340B Program and applicable provisions of 42 C.F.R. §413.65. “Hospital services” does not include: Outpatient renal dialysis services; Outpatient services provided at a limited service hospital as defined in Health-General Article, §19–301, Annotated Code of Maryland except for emergency services; or Physician services that are billed separately. Household. “Household” means, at a minimum, for an adult patient, the patient and the following individuals that live in the same dwelling: A spouse, regardless of whether the patient and spouse expect to file a joint federal or State tax return; Biological children, adopted children, or stepchildren; and All individuals on the same federal or State tax return, including anyone for whom the patient claims a personal exemption in a federal or State tax return. “Household” means, at a minimum, for a patient who is a child, the patient and the following individuals that live in the same dwelling: Biological parents, adoptive parents, stepparents, or guardians; Biological siblings, adopted siblings, or step siblings; and All individuals on the same federal or State tax return, including anyone for whom the patient’s parents or guardians claim a personal exemption in a federal or State tax return. The terms "household” and “family” are synonymous for the purposes of this chapter. Income. “Income” means total taxable income, before taxes. “Income” includes: If a hospital uses state or federal tax returns to verify income, the adjustments listed on Schedule 1 of Form 1040; and If a hospital utilizes an asset test, the value of household monetary assets, consistent with Regulation 06J of this chapter. “Initial bill” means the first billing statement provided to an individual by a hospital after the care, whether inpatient or outpatient, is provided and the individual has left the hospital. “Medical debt” means out-of-pocket expenses, including co-payments, coinsurance, and deductibles, for hospital services that are regulated by the Commission that are billed to a patient or a co-signer for the patient, excluding amounts contractually paid by another payer such as insurers, including Medicare, Medicaid, or CHIP. “Medically necessary care” including care provided in accordance with the Emergency Medical Treatment and Labor Act of 1986), means care that is: Directly related to diagnostic, preventative, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability or health condition; Consistent with current accepted standards of good medical practice; and Not primarily for the convenience of the patient, the patient’s family, or the provider. Monetary Assets. “Monetary assets” means assets in excess of $100,000 that can readily be converted into a fixed or precisely determinable amount of money, including cash and cash equivalents. “Monetary assets” include cash on hand, bank deposits, investment accounts, accounts receivable, and notes receivable. “Monetary assets” do not include retirement assets to which the Internal Revenue Service has granted preferential tax treatment, including deferred–compensation plans qualified under the Internal Revenue Code or nonqualified deferred–compensation plans. Payment Plan. “Payment plan” means an agreement between a patient, or a guarantor, to pay for a hospital service over a period of time. “Payment plan” includes: An “income-based payment plan” set forth in Regulation .05 of this chapter; and A “non-income-based payment plan” set forth in Regulation .05W of this chapter. “Qualified Maryland resident” means someone who lives in Maryland for more than 6 months of the year or whose primary residence is in Maryland, including those in Maryland for school or work. Written. “Written” means communications in paper form and communications delivered electronically, including through electronic mail, a secure web, or mobile based application such as a patient portal. “Written” does not include oral communications, including communications delivered by phone. A patient may opt out of receiving written communications required by Regulations .03—.08 of this chapter through electronic delivery methods, such as through email or a patient portal. A hospital or debt collector who communicates with a patient electronically must include in such communication, or attempt to communicate, a clear and conspicuous statement describing a reasonable and simple method by which the patient can opt out of further electronic communications by the hospital or debt collector. A hospital or debt collector may not require, directly or indirectly, that the patient, in order to opt out of electronic communication, pay any fee or provide any information other than: The patient’s opt out preferences; and The email address, telephone number for text messages, or other electronic-medium address subject to the opt-out request. If a hospital or debt collector receives notice from a patient that the patient is opting out of receiving written communications through electronic delivery methods, the hospital or the debt collector: May not provide the written communications required by Regulations .03—.08 of this chapter through electronic delivery methods; and Shall deliver the written communications through non-electronic delivery methods. Notice of Patient Opting Out of Written Communications. If a hospital receives notice from a patient that the patient is opting out of receiving written communications through electronic delivery methods, and the hospital uses a debt collector with respect to that patient, the hospital shall immediately inform the debt collector that the patient is opting out of electronic delivery methods. If a debt collector receives notice from a patient that the patient is opting out of receiving written communications through electronic delivery methods, the debt collector shall immediately inform the hospital that controls that patient account that the patient is opting out of electronic delivery methods. Each hospital shall develop an information sheet that: Describes clearly: The hospital's financial assistance policy as required in Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland; and A patient's legal rights and obligations with regard to hospital billing and collection; Informs the patient, the patient’s family, the patient’s authorized representative, or the patient’s legal guardian: That the hospital is permitted to bill outpatients a fee, commonly referred to as a facility fee, for their use of hospital facilities, clinics, supplies, and equipment, and nonphysician services, including but not limited to the services of nonphysician clinicians, in addition to physician fees billed for professional services provided in the hospital; Of the patient’s right to request and receive a written estimate of the total charges for the hospital non-emergency services, procedures, and supplies that reasonably are expected to be provided and billed for by the hospital, in addition to the good faith estimate requirements in 42 U.S.C §2799B-6, the No Surprises Act; Of the patient’s right to file a complaint with the Commission or jointly with the Health Education and Advocacy Unit of the Maryland Attorney General’s Office against a hospital for an alleged violation of Health-General Article, §§19-214.1 and 19-214.2, Annotated Code of Maryland; Of the availability of an income-based payment plan; and That physician charges, to both hospital inpatients and outpatients, are generally not included in the hospital bill and are billed separately; Provides contact information for: The individual or office at the hospital that is available to assist the patient, the patient's family, or the patient's authorized representative in order to understand: The patient's hospital bill; The patient’s rights and obligations with regard to the hospital bill, including the patient’s rights and obligations with regard to reduced-cost medically necessary care due to a financial hardship; How to apply for financial assistance; How to apply for the Maryland Medical Assistance Program and any other programs that may help pay the bill; and How to apply for a payment plan; The Maryland Medical Assistance Program; Filing a complaint with the Commission or jointly with the Health Education and Advocacy Unit of the Maryland Attorney General’s Office against a hospital for an alleged violation of Health-General Article, §§19-214.1 and 19-214.2, Annotated Code of Maryland; and Includes a section that allows the patient to initial that the patient has been made aware of the financial assistance policy. The information sheet shall be written in: Simplified language; At least 12-point type; and The patient’s preferred language or, if no preferred language is specified, each language spoken by a limited English proficient population that constitutes at least 5 percent of the overall population within the city or county in which the hospital is located as measured by the most recent census. The information sheet shall conform with Health-General Article, §19–342(d)(7) and (10), Annotated Code of Maryland. The information sheet shall be provided in writing to the patient, the patient’s family, the patient’s authorized representative, or the patient’s legal guardian: Before the patient receives scheduled medical services; Before discharge; With the hospital bill; On request; and In each written communication to the patient regarding collection of the hospital bill. The hospital bill shall include a reference to the information sheet. The Commission shall: Establish uniform requirements for the information sheet; and Review each hospital's implementation of and compliance with the requirements of this regulation. Each hospital shall submit to the Commission, at times prescribed by the Commission, the hospital's credit and collection policy. The policy shall: Provide for active oversight by the hospital of any contract for collection of debts on behalf of the hospital; Prohibit the hospital from selling any debt, except as permitted by Health-General Article, §19–214.2(m), Annotated Code of Maryland and §O of this regulation; Prohibit the hospital from: Engaging in collection activities on 100 percent of the outstanding amount of the Commission-set charge for debt sold under §O of this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland; and Collecting on judgments entered into on patient debt that was sold under §O of this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland; Reporting adverse information to a consumer reporting agency; Filing a civil action to collect a debt against a patient within 240 days after the initial bill is provided; Filing a civil action to collect a debt against a patient whose outstanding hospital medical debt is at or below $500; Forcing the sale or foreclosure of a patient’s primary residence to collect medical debt; Requesting a lien against a patient’s primary residence in an action to collect medical debt; Requesting the issuance of or otherwise knowingly taking action that would cause a court to issue a body attachment against a patient or an arrest warrant against a patient, if the hospital files an action to collect medical debt; and Requesting a writ of garnishment of wages or filing an action that would result in an attachment of wages against a patient to collect medical debt if the patient is eligible for free or reduced-cost medically necessary care, in accordance with Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland; In accordance with Health-General Article, §19-214.2(c), Annotated Code of Maryland and §G of this regulation, provide for a refund of amounts collected from a patient or the guarantor of a patient who was later found to be eligible for free medically necessary care within 240 days after the initial bill was provided under Health General Article, §19-214.1, Annotated Code of Maryland and §G of this regulation; If the hospital has obtained a judgment against or had reported adverse information to a consumer reporting agency about a patient who later was found to be eligible for free medically necessary care, in accordance with Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland, within 240 days after the initial bill was provided, require the hospital to seek to vacate the judgment or strike the adverse information; Provide a mechanism for a patient to: Request the hospital to reconsider the denial of free or reduced–cost care; and File with the hospital a complaint against the hospital or a debt collector used by the hospital regarding the handling of the patient’s bill; For a patient who is eligible for free or reduced cost-care under the hospital’s financial assistance policy, prohibit the hospital from: Charging interest on the debt owed on a bill for the patient before a court judgement is obtained; or Collecting fees or any other amount that exceeds the approved charge for the hospital service as established by the Commission; Establish a process for making payment plans available to all patients in accordance with Regulation .05 of this chapter and Health-General Article, §19-214.2(e)(3), Annotated Code of Maryland; Provide detailed procedures for the following actions: When garnishments may be applied to a patient’s or patient guarantor’s income in accordance with §I of this regulation and Health-General Article, §19-214.2(f)(4), Annotated Code of Maryland; When a lien on a patient’s or patient guarantor’s personal residence, excluding a primary resident in accordance with §I of this regulation and Health-General Article, §19-214.2(g)(2), Annotated Code of Maryland, or motor vehicle may be placed; The hospital's procedures for collecting any medical debt, consistent this regulation; The circumstances in which the hospital will seek a judgment against a patient for the patient’s medical debt, subject to §I of this regulation and Health-General Article, §19–214.2, Annotated Code of Maryland; The consideration by the hospital of patient income, assets, and other criteria set forth in this regulation; and Comply with Health-General Article, §24-2502, Annotated Code of Maryland. Consistent with Health-General Article, §19-214.2(e)(5), Annotated Code of Maryland, a hospital shall demonstrate that it attempted in good faith to meet the requirements of Health-General Article, §19-214.2(e), Annotated Code of Maryland, and the Guidelines set forth in Regulation .05 of this chapter before the hospital: Files an action to collect the patient’s medical debt; or Delegates collection activity to a debt collector for a patient’s medical debt. The hospital shall be deemed to have demonstrated that it attempted to act in good faith under Health-General Article, §19-214.2(e)(5)(i)(2), Annotated Code of Maryland and §C(2) of this regulation if, before delegating collection of a patient’s medical debt to a debt collector, the hospital: Provides the information sheet before the patient receives scheduled medical services and before discharge in accordance with Health-General Article, §19-214.2(e)(1) and (2), Annotated Code of Maryland, and in Regulation .03D(1) and (2) of this chapter; and Establishes a process for making payment plans available to all patients in accordance with Health-General Article, §19-214.2(e)(3), Annotated Code of Maryland and Regulation .05 of this chapter. In delegating any or all collection to a debt collector for a patient’s medical debt, the hospital may rely on a debt collector to engage in various activities, including: Facilitating and servicing payment plans in accordance with the Guidelines, including receiving and forwarding any payments received under a payment plan approved by the hospital; and Such other activities as the hospital may direct in collecting and forwarding payments under a payment plan. A hospital may not seek legal action to collect a patient’s medical debt until the hospital has established and implemented a payment plan policy that complies with the Guidelines. As provided by Health-General Article, §19-214.2(c), Annotated Code of Maryland: A hospital shall provide: For a refund of amounts exceeding $25 collected from a patient or the guarantor of a patient who was found to be eligible for free medically necessary care within 240 days after the initial bill is provided to the patient; and The refund to the patient not later than 30 days after determining that the patient was eligible for free medically necessary care. If a patient is enrolled in a means-tested government health care plan that requires the patient to pay out-of-pocket for hospital service, a hospital shall have a refund policy that complies with the terms of the patient’s plan. Consumer Reporting. A hospital may not commence civil action against a patient for nonpayment or delegate collection activity to a debt collector, if the hospital: Was notified in accordance with federal law by the patient or the insurance carrier that an appeal or a review of a health insurance decision is pending within the immediately preceding 60 days; Is processing a requested reconsideration of the denial of free or reduced-cost medically necessary care under Regulation .06A(1)(c)(v) of this chapter and Health-General Article, §19-214.1(b)(2)(iv), Annotated Code of Maryland, that was appropriately completed by the patient or has completed the reconsideration within the immediately preceding 60 days; or Sold the debt under §O of this regulation and Health-General Article, §19-214.2(m). A hospital shall comply with Health-General Article, §24-2502, Annotated Code of Maryland. A hospital shall report the fulfillment of a patient’s payment obligation within 60 days after the obligation is fulfilled to any consumer reporting agency to which the hospital had reported adverse information about the patient, including if the debt was sold under §O of this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland. Not later than November 1, 2025, a hospital that had reported adverse information about a patient to a consumer reporting agency shall instruct the consumer reporting agency to delete the adverse information about the patient. Civil Action. Deceased Patients. A hospital may not make a claim against the estate of a deceased patient to collect medical debt if the deceased patient was known by the hospital to be eligible for free medically necessary care, in accordance with Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland, or if the value of the estate after tax obligations are fulfilled is less than half of the medical debt owed. A hospital may offer the family of the deceased patient the ability to apply for financial assistance. A hospital may not file an action to collect medical debt until the hospital determines whether the patient is eligible for free or reduced-cost medically necessary care under Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland. At least 45 days before filing an action against a patient to collect medical debt, but not within 240 days after the initial bill is provided, a hospital shall send written notice of the intent to file an action to the patient. The notice required in §I(3) of this regulation shall: Be sent to the patient by certified mail and first class mail; Be in simplified language; Be in at least 12-point type; Include: The name and telephone number of the hospital, the debt collector, if applicable, and an agent of the hospital authorized to modify the terms of the payment plan, if any; The amount required to cure the nonpayment of medical debt, including past due payments, interest, penalties, and fees; A statement recommending that the patient seek debt counseling services; Telephone numbers and internet addresses of the Health Education Advocacy Unit of the Office of the Attorney General, available to assist patients experiencing medical debt; and An explanation of the hospital's financial assistance policy; Be provided in the patient’s preferred language or, if no preferred language is specified, English and each language spoken by a limited English proficient population that constitutes at least 5 percent of the population within the jurisdiction in which the hospital is located as measured by the most recent federal census; and Be accompanied by: An application for financial assistance under the hospital's financial assistance policy, along with instructions for completing the application for financial assistance, specific instructions about where to send the application, and the telephone number to call to confirm receipt of the application; Language explaining the availability of an income-based payment plan to satisfy the medical debt that is the subject of the hospital debt collection action; and The information sheet required under Regulation .03 of this chapter and Health-General Article, §19-214.1(f), Annotated Code of Maryland. Delegation of Collection to a Debt Collector. If a hospital delegates collection activity to a debt collector, the hospital shall: Specify the collection activity to be performed by the debt collector through an explicit authorization or contract; Require the debt collector to abide by the hospital’s credit and collection policy; Specify procedures the debt collector must follow if a patient appears to qualify for financial assistance under Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland; and Require the debt collector to: In accordance with the hospital’s credit and collection policy, provide a mechanism for a patient to file with the hospital a complaint against the hospital or the debt collector regarding the handling of patient’s bill; If a patient files a complaint with the debt collector, forward the complaint to the hospital; and Along with the hospital, be jointly and severally responsible for meeting the requirements of this regulation, Regulation .06 of this chapter, and Health-General Article, §19-214.2, Annotated Code of Maryland. Consent to Assume Liability for Medical Debt. A spouse or another individual may not be held liable for the medical debt of an individual 18 years old or older unless the individual voluntarily consents to assume liability for the patient’s medical debt. The consent shall be: Made on a separate document signed by the individual; Not solicited in an emergency room or during an emergency situation; and Not required as a condition of providing emergency or non-emergency health care services. The Board of Directors of each hospital shall review and approve the hospital’s financial assistance policy required under Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland and debt collection policy required under Regulation .04 of this chapter and Health-General Article, §19-214.2, Annotated Code of Maryland at least every 2 years. A hospital may not alter its financial assistance or credit and collection policies without approval of the Board of Directors. The Commission shall review each hospital's implementation of and compliance with the hospital's policy and the requirements of §B of this regulation. Reporting Requirements. Each hospital shall annually submit to the Commission within 120 days after the end of each hospital’s fiscal year a report including: The total number of patients by race or ethnicity, gender, and zip code of residence against whom the hospital or a debt collector used by the hospital, filed an action to collect medical debt; The total number of patients by race or ethnicity, gender, and zip code of residence with respect to whom the hospital has and has not reported or classified a bad debt; The total dollar amount of charges for hospital services provided to patients but not collected by the hospital for patients covered by insurance, including the out-of-pocket costs for patients covered by insurance, and patients without insurance; and For hospital debts owed by patients of the hospital that the hospital sold to a governmental unit, contractor, or nonprofit organization under Health-General Article, §19-214.2(m), Annotated Code of Maryland and §O of this regulation: The total dollar amount of the debt sold by the hospital for the reporting year; The total dollar amount paid by the hospital to the unit, contractor, or nonprofit organization who purchased the debt; and The total number of patients whose debt was sold, in full or in part, to the unit, contractor, or nonprofit organization who purchased the debt. The Commission shall post the information submitted under §N(1) of this regulation on its website. Selling Medical Debt. Consistent with Health-General Article, §19-214.2(m), Annotated Code of Maryland, a hospital may sell debt owed to the hospital by a patient for hospital services to a governmental unit, an entity that is under contract with the governmental unit, or to a nonprofit organization that is exempt from taxation under 26 U.S.C. §501(c)(3) of the Internal Revenue Code for the sole purpose of canceling the debt. The contract between the hospital and the governmental unit, entity that is under contract with the governmental unit, or nonprofit organization purchasing the debt shall state that the sole purpose of the sale of the debt is to cancel the debt. The patient is not responsible to the hospital, the governmental unit, the entity that is under contract with the governmental unit, or the nonprofit organization for any amount of the debt that is sold, or any interest, fees, or costs associated with the debt or the sale. Debt sold under this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland: Must be for hospital services provided at least 2 years before the date of the sale; May not be expected to yield additional reimbursements from a third-party payor; May not be subject to an open appeal with an insurance company; and Must be for an individual whose family income is at or below 500 percent of the federal poverty level or who has medical debt exceeding 5 percent of the patient’s family income, as determined by the governmental unit, contractor, or nonprofit organization purchasing the debt. Debt sold under this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland, may be sold with a reduction of Commission charges. The Commission shall treat the amount of payments to hospitals under this subsection as an offset to uncompensated care amounts reported by hospitals. The purchaser of the debt shall: Notify the patient that the debt has been canceled; and If the hospital obtained a judgment against the patient or reported adverse information to a consumer reporting agency about the patient, seek to vacate the judgment or strike the adverse information. If a hospital sells hospital medical debt under this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland, the hospital must immediately dismiss actions pending against a patient for collection of that debt. Scope. As described in this regulation, the Guidelines for Hospital Payment Plans apply to any income-based payment plan offered by a hospital to a patient to pay for medically necessary hospital services after the services are provided. “Income” in this regulation means household monthly income. Prepayment Plans. Nothing in the Guidelines prevents a hospital from offering patients arrangements to make payments prior to service, provided that: A hospital may not require or steer a patient to enter into such an arrangement solely to avoid the application of these Guidelines; Before a hospital requests pre-payment for a hospital service, the hospital shall: Comply with the notice provisions of Health-General Article, §19-214.1, Annotated Code of Maryland, and Regulations .03 and .06 of this chapter; Advise the patient about the availability of financial assistance; Process any request for financial assistance; and Advise the patient about the availability of income-based payment plans, including information about the 5 percent cap on monthly payment amounts under §F(1) of this regulation; and Such an arrangement terminates once the hospital service is rendered. Unregulated Services. These Guidelines apply only to hospital services that are regulated by the Commission. These Guidelines do not apply to services that are not regulated by the Commission, including physician services. Limitation of the Guidelines. These Guidelines do not prevent hospitals from extending payment plans for services, such as physician services, or at times that are outside the parameters of the Guidelines. Except as otherwise required by law or regulation, payment plans that are outside the parameters of these Guidelines are not subject to the Guidelines. Access to Income-Based Payment Plans. Availability of Income-Based Payment Plans. Maryland hospitals shall make income-based payment plans available to all patients who are Maryland residents, including individuals temporarily residing in Maryland due to work or school, irrespective of their: Insurance status; Citizenship status; Immigration status; or Eligibility for reduced-cost medically necessary care, including reduced-cost medically necessary care due to financial hardship, under Regulation .06 of this chapter. Treatment of Nonresidents and Unregulated Services. These Guidelines do not prevent a hospital from extending payment plans to patients who are not described in §B(1) of this regulation. These Guidelines do not prevent a hospital from extending payment plans to patients for services that are not regulated by the Commission. Except as required by §U of this regulation or by other law or regulation, payment plans for patients which are not described in §B(1) of this regulation and payment plans for services that are not regulated by the Commission are not subject to the Guidelines under this regulation. Notice Requirements. Notice of Availability of an Income-Based Payment Plan. Posted Notice. A notice shall be posted in conspicuous places throughout the hospital, including the billing office, informing Maryland residents of the availability of an income-based payment plan and whom to contact at the hospital for additional information. If the hospital uses a vendor to assist with financial assistance eligibility, billing, or debt collection, such as a debt collector or eligibility vendor, the hospital shall ensure that the vendor posts a notice in a conspicuous place on their website or online payment portal, informing Maryland residents of the availability of an income-based payment plan and whom to contact at the hospital or debt collector for additional information. Placement on the website or online payment portal should be based on the best interest of the patient. Information Sheet. A written notice of the availability of an income-based payment plan shall be contained in the information sheet required under Regulation .03 of this chapter, including clarity on the availability of income-based payment plans for Maryland residents, and, if payment plans for non-residents are included in the hospital’s credit and collection policy, the availability of such plans for non-residents. Before a Prepayment Plan. Before a patient enters into a prepayment plan as described in §A(2) of this regulation for a medically necessary hospital service, a hospital shall provide a written notice of the availability of an income-based payment plan to a patient. On a Bill. On the same page of the bill that includes the amount due and due date, the hospital shall provide notice that a lower monthly payment amount may be possible through an income-based plan, in the same font and style as the total amount due notification. Online Payment Portal. On both the page of the online payment portal that states the amount due, and where the consumer enters the amount being paid by the consumer, the hospital shall provide, in the same font and style as the amount due notification, notice informing Maryland residents of the availability of an income-based monthly payment plan and information, including a telephone number and email address, in order to contact the hospital for additional information. Notice of Terms Before Execution. A hospital shall provide written notice of the terms of an income-based payment plan to a patient before the patient agrees to enter the income-based payment plan. The terms of the income-based payment plan shall include: The amount of medical debt owed to the hospital; The interest rate applied to the income-based payment plan and the total amount of interest expected to be paid by the patient under the income-based payment plan; The amount of each periodic payment expected from the patient under the income-based payment plan; The number of periodic payments expected from the patient under the income-based payment plan; The expected due dates for each payment from the patient; The expected date by which the account will be paid off in full; The treatment of any missed payments, including missed payments and default as described in §P and T of this regulation; That there are no penalties for early payments; and Whether the hospital plans to apply a periodic recalculation of monthly payment amounts as described in §N of this regulation and the process for such recalculation. Notice of Plan After Execution. A hospital shall promptly provide a written income-based payment plan, including items listed in §C(2) of this regulation, to the patient following execution by all parties. The income-based payment plan shall be provided to the patient at least 20 days before the due date of the patient’s first payment under the income-based payment plan. Financial Assistance. Before entering into an income-based payment plan with a patient, hospitals shall evaluate if the patient is eligible for financial assistance, including free and reduced-cost medically necessary care, including reduced-cost medically necessary care due to financial hardship, in accordance with Regulation .06 of this chapter. Hospitals shall: Apply the financial assistance reduction before entering into an income-based payment plan with a patient; and Use any information collected for determining financial assistance under Regulation .06 of this chapter to establish the 5 percent monthly payment threshold for payment plans under Regulation .05F of this chapter. Offer Required. Hospitals must offer income-based payment plans that meet the requirements of these Guidelines. Monthly Payment Amounts. Under an income-based payment plan subject to these Guidelines, a hospital may not require a patient to make total payments in a month that exceed 5 percent of the lesser of the patient’s household income. §F(1) of this regulation applies to total amounts due under the plan, including both principal and interest, but does not apply to any catch-up payments, such as payments described under §P(1) of this regulation. A hospital shall calculate the monthly payment amount threshold under §F(1) of this regulation by dividing income level by household size and multiplying by .05 percent. Determining the Household Size. The hospital shall determine the size of the patient’s household using the number reported on tax returns, if provided the number of tax filers and dependents listed on the tax return provided by the patient. For example, if a married couple files jointly and has three dependents, the number of tax filers and dependents would equal five. If a patient files as an individual and the patient is not a dependent and has no dependents, the number of tax filers would equal one. If the patient has not provided a tax return, the hospital shall ask the patient to provide the number of individuals in the household. Expenses. A hospital may reduce the amount of the monthly payment due under an income-based payment plan upon consideration of household expense information provided by a patient. Application to Multiple Income-based Payment Plans. Hospitals. A hospital shall ensure that the total monthly payment amount for all income-based payment plans provided to a patient by the hospital, when added up collectively, does not exceed the income limitation under §F(1) of this regulation. Hospital System. A hospital system shall ensure that the total monthly payment amount for all income-based payment plans provided to a patient by all hospitals in the hospital system, when added up collectively, does not exceed the income limitation under §F(1) of this regulation. Duration of Income-Based Payment Plan. The duration of an income-based payment plan, in months, is determined by the total amount owed, and interest, if interest applies, divided by the total amount of the payment due each month, subject to the limitation that no monthly payment may exceed 5 percent of the patient’s income as calculated under §F(1)of this regulation. Solicitation of Early Payments Prohibited. Hospitals may not solicit, steer, or mandate patients to pay an amount in excess of the monthly payment amount provided for in an income-based payment plan. Application of Partial Payments. A hospital shall apply partial payments in a manner most favorable to the patient. Interest and Fees. No Interest for Patients Eligible for Financial Assistance. For a patient who is eligible for free or reduced-cost medically necessary care under the hospital’s financial assistance policy under Regulation .06 of this chapter and Health-General Article, §19–214.1, Annotated Code of Maryland, the hospital may not charge interest or fees on any medical debt amount owed under an income-based payment plan. Allowable Interest. A hospital may charge interest under an income-based payment plan for a patient who is not eligible for free or reduced-cost medically necessary care, as described in §L of this regulation. A hospital is not required to charge interest for a payment plan. Interest Rate. An income-based payment plan may not provide for interest in excess of an effective rate of simple interest of 6 percent per annum on the unpaid principal balance of the payment plan. A hospital may not set an interest rate that results in negative amortization. Payers subject to Insurance Article, §15-1005, Annotated Code of Maryland, shall comply with its provisions. Timing. Interest may not begin before 240 days after the initial bill is provided. Late payments. A hospital may not charge additional fees or interest for late payments. Early Payment. Prepayment Allowed. Patients may, on a voluntary basis, pre-pay, in whole or in part, any amounts owed under an income-based payment plan. Any prepayment made under §M(1) of this regulation is not subject to the monthly income payment limitations of §F(1) of this regulation. No Fees or Penalties. A hospital may not assess fees or otherwise penalize early payment of an income-based payment plan. Limited Modifications of Income-based Payment Plans. Change in Income. If a patient with an income-based payment plan notifies a hospital that the patient’s income has changed, then the hospital shall offer to modify the income-based payment plan to meet the requirement of §N(6) of this regulation. Expenses. Before modifying an income-based payment plan, a hospital shall consider information provided by a patient about changes in household expenses in considering a patient request to modify a payment plan. No Increase in Interest Rate. A hospital may not increase the interest rate on an income-based payment plan when making a modification to an income-based payment plan under this Guideline. Limitation on Payment Amount. A hospital may not modify an income-based payment plan in a way that requires a patient to make a monthly payment that exceeds the percent of the patient’s income used to set the monthly payment amount under the initial income-based payment plan as provided for in §F of this regulation. Change in Duration. The duration of a modified income-based payment plan, in months, is determined by the total amount owed, and interest, if interest applies, divided by the total amount of the payment due each month, subject to the limitation under §F of this regulation. Process for Modifying an Income-Based Payment Plan. Prompt Response to Patient Request. If a patient requests a modification to the terms of the payment plan, the hospital shall respond in a timely manner and may not refer the outstanding balance owed to a collection agency or for legal action until 30 days after providing a written response to the patient’s request for a modification of the payment plan. Reconsideration for Financial Assistance. If a patient makes a request for modification of a payment plan, the hospital shall consider if such patient is eligible for financial assistance, including free medically necessary care, reduced-cost medically necessary care, and reduced-cost care due to financial hardship under Regulation .06 of this chapter. The hospital will apply the financial assistance reduction in its modification of the payment plan. Mutual Agreement. A hospital may not modify a payment plan without mutual agreement between the hospital and the patient before the changes are made. Notice of Terms. The hospital shall provide the patient with a written notice of all payment plan terms, consistent with the requirements of §C of this regulation, upon modifying a payment plan under this Guideline. Hospital-Initiated Changes to Income-Based Payment Plans Based on Changes to Patient Income. Recalculation Allowed. A hospital may, in the terms of an initial income-based payment plan under §C(2) of this regulation that exceeds 3 years in length, provide for periodic recalculations to the amount of the monthly payments and the duration of the payment plan based on changes in the patient’s income as subject to and calculated under §N(5) of this regulation. Notice Included in Initial Income-Based Payment Plan. The hospital may only recalculate payment amounts under an income-based payment plan if the hospital included the process for such recalculation in the notice provided to the patient before they entered into the income-based payment plan, in accordance with §C(2) of this regulation. The patient’s agreement to enter into the income-based payment plan after receiving that notice constitutes consent to the payment recalculations allowed under §P of this regulation. Limitations on Modification Apply. The provisions of §N of this regulation relating to limitations of payment plan modifications apply to payment recalculations for income-based payment plans under §O of this regulation. Frequency of Recalculation. A hospital may not seek a recalculation of the monthly payment amount under an income-based payment plan, as provided for under §O(1) of this regulation more than once every 3 years. Treatment of Missing Information. If a patient does not provide income information on the request of the hospital seeking to make a change to an income-based payment plan under §O of this regulation and the patient is in good standing on the patient's payments under the income-based payment plan, the hospital may not change the monthly payment amounts under the income-based payment plan. Treatment of Missed Payments. First Missed Payment. A hospital may not deem a patient to be noncompliant with an income-based payment plan if the patient makes at least 11 scheduled monthly payments within a 12-month period. Subject to §P(1)(c) of this regulation, the hospital shall permit the patient to repay the missed payment amount at any time, as determined by the patient, including through a set of partial payments. No later than 30 days after the first missed payment in a 12-month period, the hospital shall notify the patient of the missed payment and inform the patient that the patient may be in default if they do not pay the amount of the missed payment within 12 months or if they miss additional payments within the 12-month period. The notice will give the patient the option to pay the missed payment by paying the amount of the missed payments in one of the following ways: 11 increments over the subsequent 11 months; A single payment; or Another approach, as specified by the patient. With respect to a patient that has missed a single monthly payment in a 12-month period, the hospital shall provide the patient with a method to designate whether any amount of a payment paid in the subsequent 12-month period is to be applied to the amount of missed payment or applied in a different manner. With respect to a patient that has missed a single monthly payment in a 12-month period, if the hospital receives a payment and the patient has not designated how that payment is to be applied, the hospital shall first apply the amount to any payment that is due in the 31-day period following the date the payment is received. If there is no payment due in the next month, the hospital shall apply the amount of the payment to the missed payment. If the amount of the payment exceeds the amount of any payment that is due in the 31-day period following the date the payment is received, the excess amount shall be applied to the missed payment. The hospital may consider a patient to be in default on the income-based payment plan if the missed payment is not repaid in full by the end of the 12-month period that begins on the date of the missed payment under §P(1) of this regulation. Additional Missed Payments. A hospital may forbear the amount of any additional missed payments that occur in a 12-month period. If a hospital forbears the amount of any additional missed payments that occur in a 12-month period, the hospital shall allow the patient to continue to participate in the income-based payment plan. If a hospital forbears the amount of any additional missed payments that occur in a 12-month period, the hospital may not refer the outstanding balance owed to a collection agency or for legal action. The hospital shall recapitalize the amount of any missed payments that were subject to forbearance under this §P of this regulation as additional payments at the end of the income-based payment plan, thereby extending the length of the income-based payment plan. The hospital shall provide written notice to the patient of the treatment of the missed payments, including any extension of the length of the income-based payment plan. Treatment of Loans and Extension of Credit. After a hospital service is provided to the patient, a hospital, hospital affiliate, or third-party in partnership with a hospital may not make any loan or extension of credit to the patient in connection with a medically necessary hospital service that is inconsistent with the guidelines for payment plans in this regulation resulting from that service. Application of Credit Provisions of Maryland Commercial Law Article and Licensing Provisions of Financial Institutions Article. An income-based payment plan is an extension of credit subject to Maryland credit regulations under Commercial Law Article, Title 12, Annotated Code of Maryland and any applicable licensing provisions of Financial Institutions Article, Title 11, Annotated Code of Maryland. Books and Records. A hospital shall retain books and records on income-based payment plans for at least 3 years after the income-based payment plan is closed. Default. If a patient defaults on an income-based payment plan and the parties are unable to agree to a modification, then the hospital shall follow the provisions of its credit and collection policy established in accordance with Regulation .04 of this chapter, before a hospital may write this medical debt off as bad debt. With respect to the amounts covered by the income-based payment plans, a patient who is on an income-based payment plan and is not in default on that payment plan may not be considered in arrears on their debt to the hospital when the hospital is making decisions about scheduling health care services. Non-Income-Based Payment Plans. Other Payment Plans Allowed. A hospital may offer a non-income-based payment plan under these Guidelines, but must first offer the patient an income-based payment plan. Application of Guidelines. Consistent with the Guidelines for Hospital Payment Plans and consistent with the intent of Health-General Article, §19-214.2, Annotated Code of Maryland, the following provisions of this regulation apply to non-income-based payment plans in the same manner such provisions apply to income-based payment plans: §A of this regulation, regarding scope; §B of this regulation, regarding access to payment plans; §C(2) of this regulation, regarding notice of payment plan terms before execution; §C(3) of this regulation, regarding notice of plan after execution; §D of this regulation, regarding financial assistance; §L of this regulation, regarding interest and fees; §M(1)(a) and (2) of this regulation, regarding early payments; §N(6) of this regulation, regarding modifications of payment plans; §Q of this regulation, relating to treatment of loans and extensions of credit; §R of this regulation, relating to the application of credit provisions of Maryland Commercial Law Article and the licensing provisions of Financial Institutions Article; §S of this regulation, relating to books and records; and §T of this regulation, relating to default. Notice. Notice of Terms Before Execution. In addition to complying with the terms of §C(2) of this regulation, the hospital must include notice that the patient may apply for an income-based payment plan at any time in the notice of terms before execution of a non-income-based payment plan. Notice of Plan After Execution. The hospital must include the notice required in §U(3)(a) of this regulation in the notice of the payment plan after execution that is required by §C(3) of this regulation. Notice with Bills. Each bill for a non-income-based payment plan shall include a notice that informs the patient that income-based payment plans are available, which could result in lower monthly payments and provides information on how to apply for such plans. Consent. Before entering into a non-income-based repayment plan with a patient, the hospital must obtain consent from the patient that records that the patient affirms the following: The hospital offered the patient an income-based payment plan; The income-based payment plan limits monthly payment amounts to 5 percent of the patient’s monthly income; The income-based payment plan may result in lower monthly payment amounts than the monthly payment amounts under the non-income-based repayment plan; The patient has the opportunity to disclose their income and determine the payment amount under the income-based payment plan; and The patient is declining to enter an income-based payment plan and is consenting to enter a non-income-based repayment plan. Modification of a Non-Income-Based Payment Plan: In addition to complying with the terms of §N(6) of this regulation, before modifying a non-income-based payment plan: The hospital shall offer the patient an income-based payment plan; and, If the patient declines the income-based payment plan, obtain the consent required under §U(4) of this regulation. Default on a Non-Income-Based Payment Plan. If the patient defaults on a non-income-based payment plan, the hospital must offer an income-based payment plan to the patient before the hospital follows the provisions of its credit and collection policy to collect the debt. The offer provided under §U(6)(a) of this regulation must be sent separately from a bill. Steering. A hospital may not steer patients to non-income-based payment plans, or third-party credit providers, in such a manner that discourages patients from entering into income-based payment plans. A hospital may not steer patients to revolving credit products in such a manner that discourages patients from entering into either income-based payment plans or non-income based payment plans under this regulation. Financial Assistance Policy. Requirements. Each hospital and each chronic care hospital under the jurisdiction of the Commission shall develop a written financial assistance policy for providing free and reduced-cost medically necessary care to low-income patients who lack health care coverage or to patients whose health insurance does not pay the full cost of the hospital bill. A hospital shall provide written notice of the hospital's financial assistance policy to the patient, the patient's family, or the patient's authorized representative before discharging the patient and in each communication to the patient regarding collection of the hospital bill. The required notice shall state that the patient has up to 240 days after the day the patient receives the initial hospital bill to apply for financial assistance from the hospital. The hospital shall obtain documentation ensuring that the patient or the patient’s authorized representative acknowledges the patient’s receipt of the notice before discharging the patient. If a patient chooses not to apply for financial assistance, the patient’s documented acknowledgement shall indicate that the patient is not applying for financial assistance on the day of the acknowledgment but may apply within 240 days immediately following the patient’s receipt of the initial hospital bill. The financial assistance policy shall provide at a minimum: Free medically necessary care to patients with family income at or below 200 percent of the federal poverty level, consistent with the provisions of §A(2) of this regulation; Reduced-cost medically necessary care to patients with family income between 200 and 300 percent of the federal poverty level, consistent with the provisions of §A(2) of this regulation; A description of the payment plan required under Health-General Article, §19-214.2(d), Annotated Code of Maryland and Regulation .05 of this chapter; and A mechanism for a patient, irrespective of that patient’s insurance status, to request the hospital to reconsider the denial of free or reduced-cost medically necessary care, including the address, phone number, facsimile number, email address, mailing address, and website of the Health Education and Advocacy Unit, which can assist the patient or patient’s authorized representative in filing and mediating a reconsideration request. If a patient is eligible for reduced-cost medically necessary care under §A(1)(c)(ii) of this regulation, the hospital shall, at a minimum, reduce the patient’s out-of-pocket expenses for the hospital services: For a patient with family income of at least 201 percent but not more than 250 percent of the federal poverty level, by 75 percent; and For a patient with family income of more than 250 percent but not more than 300 percent of the federal poverty level, by 60 percent. The hospital shall provide free and reduced-cost medically necessary care to all qualified Maryland residents, regardless of their citizenship or immigration status. The hospital shall provide free and reduced-cost medically necessary care under §A(1)(c) of this regulation to all qualified Maryland residents, regardless of whether the patient resides in the hospital’s service area. The financial assistance policy applies to all medically necessary hospital services provided to qualified Maryland residents. Hospitals may not exclude non-urgent or elective, but medically necessary, care from their financial assistance policy. The financial assistance policy shall calculate a patient’s eligibility for free medically necessary care under §A(1)(c)(i) of this regulation and Health-General Article, §19-214.1(b)(2)(i), Annotated Code of Maryland, or reduced-cost medically necessary care under §A(1)(c)(ii) of this regulation and Health-General Article, §19-214.1(b)(2)(ii), Annotated Code of Maryland, at the date of service or updated, as appropriate, to account for any change in the financial circumstances of the patient that occurs within 240 days after the initial bill is provided. The hospital shall consider any change in the patient’s financial circumstance in accordance with Health-General Article, §19-214.1(b)(11), Annotated Code of Maryland. Income Documentation. Hospitals shall accept generally acceptable forms of documentation that verify income, such as tax returns, pay stubs, and W2s to evaluate if the patient is eligible for financial assistance, including free and reduced-cost medically necessary care, including reduced-cost medically necessary care due to financial hardship, in accordance with this regulation . Hospitals shall use available information, including information provided by the patient, to approximate the patient’s income if the patient has not provided their tax returns, pay stubs, W2s, or another form of documentation. Income Attestations. Hospitals may accept patient attestation of the patient’s monthly or annual income and the number of filers and dependents on their tax return without documentation. Such an attestation shall include the patient’s income and the number of filers and dependents on their tax return. If the patient provides an attestation of income the hospital is not required to conduct any additional income verification. A hospital’s inability to obtain complete income information does not preclude the hospital's ability to reasonably predict a patient’s income for the purposes of providing financial assistance. For example, a hospital may multiply income reported at the monthly level by 12 to determine income at the annual level, allowing for reasonably predictable changes in income throughout the year. Presumptive Eligibility for Free Medically Necessary Care. Unless otherwise eligible for Medicaid or CHIP, patients who are beneficiaries/recipients of the following means-tested social services programs are deemed eligible for free medically necessary care: Households with a child in the free or reduced lunch program and is eligible for the program based on the household’s income; Supplemental Nutritional Assistance Program (SNAP); Low-income-household energy assistance program; Primary Adult Care Program (PAC), until such time as inpatient benefits are added to the PAC benefit package; Women, Infants and Children (WIC); or Other means-tested social services programs deemed eligible for hospital free medically necessary care policies by the Maryland Department of Health and the Commission, consistent with this regulation. Hospital Reports. Each hospital shall submit to the Commission within 120 days after the end of each hospital’s fiscal year: The hospital’s financial assistance policy developed in accordance with this regulation; and An annual report on the hospital's financial assistance policy that includes: The total number of patients who completed or partially completed an application for financial assistance during the prior year; The total number of inpatients and outpatients who received free medically necessary care during the immediately preceding year and reduced-cost medically necessary care for the prior year; The total number of patients who received financial assistance during the immediately preceding year, by race or ethnicity and gender; The total number of patients who were denied financial assistance during the immediately preceding year, by race or ethnicity and gender; The total cost of hospital services provided to patients who received free medically necessary care; and The total cost of hospital services provided to patients who received reduced-cost medically necessary care that was covered by the hospital as financial assistance or that the hospital charged to the patient. Financial Hardship Policy. Subject to Regulation .05D of this chapter, the financial assistance policy required under §A of this regulation and Health-General Article, §19-214.1, Annotated Code of Maryland, shall provide reduced-cost medically necessary care to patients with family income below 500 percent of the federal poverty level who have a financial hardship. If a patient has received reduced-cost medically necessary care due to a financial hardship, the patient or any immediate family member of the patient living in the same household: Shall remain eligible for reduced-cost medically necessary care when seeking subsequent care at the same hospital during the 12-month period beginning on the date on which the reduced-cost medically necessary care was initially received; and To avoid an unnecessary duplication of the hospital’s determination of eligibility for free and reduced-cost medically necessary care, shall inform the hospital of the patient’s or family member’s eligibility for the reduced-cost medically necessary care. If a patient is eligible for reduced-cost medically necessary care under a hospital’s financial hardship policy, the hospital shall, at a minimum, reduce the patient’s out-of-pocket expenses for hospital services: For a patient with family income of at least 201 percent but not more than 250 percent of the federal poverty level, by 75 percent; For a patient with family income of more than 250 percent but not more than 300 percent of the federal poverty level, by 60 percent; For a patient with family income of more than 300 percent but not more than 350 percent of the federal poverty level, by 50 percent; For a patient with family income of more than 350 percent but not more than 400 percent of the federal poverty level, by 45 percent; For a patient with family income of more than 400 percent but not more than 450 percent of the federal poverty level, by 40 percent; and For a patient with family income of more than 450 percent but not more than 500 percent of the federal poverty level, by 35. The Commission may, by regulation, establish income thresholds higher than those in this regulation: Patient mix; Financial condition; Level of bad debt experienced; Amount of financial assistance provided; and Other relevant factors. Notice Requirements. A notice shall be posted in conspicuous places throughout the hospital including the billing office informing patients of their right to apply for financial assistance and who to contact at the hospital for additional information. If the hospital uses a vendor to assist with financial assistance eligibility, billing, or debt collection, such as a debt collector or eligibility vendor, that vendor shall post a notice in a conspicuous place on their website or online payment portal, informing patients of their right to apply for financial assistance, providing a link to the financial assistance application, and providing information on how to submit the application. Placement on the website or online payment portal should be based on the best interest of the patient. The notice required under §E of this regulation shall be in: Simplified language; At least 10-point type; and The patient’s preferred language or, if no preferred language is specified, each language spoken by a limited English proficient population that constitutes at least 5 percent of the overall population within the city or county in which the hospital is located as measured by the most recent census. Financial Assistance Application. Each hospital shall: Use a Financial Assistance Application in the manner prescribed by the Commission in order to determine eligibility for free and reduced-cost medically necessary care; Use a Financial Assistance Application that meets the requirements of this regulation and is consistent with the Uniform Financial Assistance Application; and Establish a mechanism to provide a Financial Assistance Application to patients regardless of their insurance status. A hospital may require from patients or their guardians only those documents required to validate the information provided on the application. Asset Test Requirements. A hospital may utilize a monetary asset test when determining eligibility for financial assistance, using the definition of monetary assets as defined in Regulation 01B of this chapter. The Commission shall post a process on its website for a patient or a patient’s authorized representative to file with the Commission a complaint against a hospital for an alleged violation of Health-General Article, §§19-214.1 or 19-214.2, Annotated Code of Maryland. The process established by the Commission shall include the option for a patient or a patient’s authorized representative to file the complaint jointly with the Commission and the Health Education and Advocacy Unit. The process shall conform to the requirements of Health-General Article, §19-214.3, Annotated Code of Maryland. In addition to the good faith estimate requirements set forth in the Public Health Service Act, 42 U.S.C §2799B-6, the No Surprises Act, on request of a patient made before or during treatment, a hospital shall provide to the patient a written estimate of the total charges for the hospital services, procedures, and supplies that reasonably are expected to be provided and billed to the patient by the hospital. The written estimate shall state clearly that it is only an estimate and actual charges could vary. A hospital may restrict the availability of a written estimate to normal business office hours. The provisions set forth in §A—C of this regulation do not apply to emergency services. This chapter does not diminish any obligations of a debt collector, as defined under Regulation .01 of this chapter, under other applicable laws or regulations, including, without limitation, any requirement for the debt collector to obtain a collection agency license from the State Collection Agency Licensing Board in accordance with Business Regulation Article, Title 7, Subtitle 3, Annotated Code of Maryland. Health-General Article, §§19-214.2, 19-214.3, 19-207, and 19-219, Annotated Code of Maryland Effective date: December 11, 2025 (52:24 Md. R. 1198)