<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".03" citation="COMAR 31.17.01.03" title_num="31" subtitle_num="17" chapter_num="01" heading="Selection Criteria for Plan Administrator.">
  <paragraph num="A.">
    <text>The Board may select an administrator to be the Plan Administrator only if the administrator:</text>
    <paragraph num="(1)">
      <text>Satisfies the requirements listed in §§C—I of this regulation; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Meets all other terms that are established in any contract between the administrator and the Board.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>The Board may select more than one Plan Administrator to administer different benefits or administrative functions of the Plan.</text>
  </paragraph>
  <paragraph num="C.">
    <text>Proven Ability to Provide Health Insurance Coverage to Individuals. An administrator shall provide evidence to the Board that it has at least 3 years experience of:</text>
    <paragraph num="(1)">
      <text>Providing health plan benefits under insured contracts that cover at least 15,000 lives per year;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Administering health plans for self-funded employer health plans that cover at least 15,000 lives per year;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Enrolling at least 15,000 lives per year in the administrator's capacity as a managed care organization; or</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Insuring, administering, or enrolling at least 15,000 lives per year through a combination of any of the health plans or programs listed in §C(1)—(3) of this regulation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Efficiency and Timeliness of Administrator's Claim Processing Procedures.</text>
    <paragraph num="(1)">
      <text>A carrier shall provide evidence to the Board that it has procedures in place to comply with:</text>
      <paragraph num="(a)">
        <text>The claim processing procedures required under Insurance Article, §§15-1004—15-1006, 15-1008, and 15-1009, Annotated Code of Maryland, for members covered under the Plan; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Any notice requirements specified by the Board in the request for proposals for the Plan Administrator.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>An administrator that is not a carrier shall provide the following to the Board:</text>
      <paragraph num="(a)">
        <text>A detailed description of the claim procedures and processes that the administrator uses;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>An assurance that the administrator shall accept the uniform claims form as adopted by the Commissioner under Insurance Article, §15-1003, Annotated Code of Maryland, for claims submitted on behalf of members of the Plan;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>An assurance that the administrator shall comply with the uniform claims forms regulations in COMAR 31.10.11 for claims submitted on behalf of members of the Plan;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>An assurance that the administrator shall pay claims for members of the Plan within the time required by Insurance Article, §15-1005, Annotated Code of Maryland;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>An assurance that if the administrator denies a member's claim, the administrator, upon request of the member, shall give written notice to the member that states fully the reason for the denial;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>An assurance that the administrator shall comply with the requirements regarding retroactive denial of reimbursement as found in Insurance Article, §15-1008, Annotated Code of Maryland, for claims for members of the Plan;</text>
      </paragraph>
      <paragraph num="(g)">
        <text>An assurance that the administrator shall comply with the requirements regarding reimbursement for preauthorized care as found in Insurance Article, §15-1009, Annotated Code of Maryland, for claims for members of the Plan; and</text>
      </paragraph>
      <paragraph num="(h)">
        <text>An assurance that the administrator shall comply with any notice requirements specified by the Board in the request for proposals for the Plan Administrator.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>Estimate of Total Charges for Administering the Plan. Each administrator that responds to a request for proposals to be the Plan Administrator shall provide, in the manner requested by the Board, an estimate of the total charges for administering the Plan.</text>
  </paragraph>
  <paragraph num="F.">
    <text>Proven Ability to Apply Effective Cost Containment Programs.</text>
    <paragraph num="(1)">
      <text>Each administrator that responds to a request for proposals to be the Plan Administrator shall provide to the Board:</text>
      <paragraph num="(a)">
        <text>A description of each cost containment program that the administrator has available to use in the State; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>An estimate of the savings that each cost containment program will provide to the Plan.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Use of Private Review Agents. The Administrator shall provide to the Board an assurance that any utilization review performed for a member of the Plan shall be performed by a private review agent that has a certificate from the Commissioner to perform utilization review in the State.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>Financial Condition and Stability of the Plan Administrator.</text>
    <paragraph num="(1)">
      <text>A carrier shall be deemed to meet the financial condition and stability requirements for the Plan Administrator if the carrier is:</text>
      <paragraph num="(a)">
        <text>An insurer with a certificate of authority in good standing to write health insurance in the State;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A nonprofit health service plan with a certificate of authority in good standing to operate in the State; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A health maintenance organization with a certificate of authority in good standing to operate in the State.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>An administrator who is not a carrier shall:</text>
      <paragraph num="(a)">
        <text>Be registered in the State as an administrator under Insurance Article, Title 8, Subtitle 3, Annotated Code of Maryland; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>File with the Board the administrator's financial statements audited by an independent certified public accountant from the preceding two calendar years.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="H.">
    <text>Provider Panel Requirements.</text>
    <paragraph num="(1)">
      <text>A carrier shall provide evidence to the Board that it has procedures in place to comply with:</text>
      <paragraph num="(a)">
        <text>The provider panel requirements of Insurance Article, §§15-112 and 15-115, Annotated Code of Maryland, for any provider panels used to provide health care services to Plan members;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The compensation of health care practitioners requirements of Insurance Article, §15-113, Annotated Code of Maryland, for services rendered to Plan members; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The uniform credentialing form requirements of Insurance Article, §15-112.1, Annotated Code of Maryland, when credentialing providers for the Plan.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>An administrator that is not a carrier shall provide assurances to the Board that the administrator shall comply with:</text>
      <paragraph num="(a)">
        <text>The provider panel requirements of Insurance Article, §§15-112 and 15-115, Annotated Code of Maryland, for any provider panels used to provide health care services to Plan members;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The compensation of health care practitioners requirements of Insurance Article, §15-113, Annotated Code of Maryland, for services rendered to Plan members; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The uniform credentialing form requirements of Insurance Article, §15-112.1, Annotated Code of Maryland, when credentialing providers for the Plan.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="I.">
    <text>Use of Standardized Forms.</text>
    <paragraph num="(1)">
      <text>A carrier shall provide evidence to the Board that it has procedures in place to comply with the uniform consultation referral form requirements of Insurance Article, §15-119, Annotated Code of Maryland and COMAR 31.10.12 for Plan member referrals.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>An administrator that is not a carrier shall provide written assurance to the Board that it will comply with the uniform consultation referral form requirements of Insurance Article, §15-119, Annotated Code of Maryland and COMAR 31.10.12 for Plan member referrals.</text>
    </paragraph>
  </paragraph>
</regulation>