reglab/statecodes huggingface dataset:
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 14 - Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms › Section 15-1406 - Eligibility of Individual to Enroll Under Group Plan

(a)    A carrier may not establish rules for eligibility of an individual to enroll under a group health benefit plan based on any health status-related factor.
(b)    Subsection (a) of this section does not:
(1)    require a carrier to provide particular benefits other than those provided under the terms of the particular health benefit plan; or
(2)    prevent a carrier from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled in the health benefit plan.
(c)    Rules for eligibility to enroll under a plan include rules defining any applicable waiting periods for enrollment.
(d)    A carrier shall allow an employee or dependent who is eligible, but not enrolled, for coverage under the terms of a group health benefit plan to enroll for coverage under the terms of the plan if:
(1)    the employee or dependent was covered under an employer-sponsored plan or group health benefit plan at the time coverage was previously offered to the employee or dependent;
(2)    the employee states in writing, at the time coverage was previously offered, that coverage under an employer-sponsored plan or group health benefit plan was the reason for declining enrollment, but only if the plan sponsor or issuer requires the statement and provides the employee with notice of the requirement;
(3)    the employee’s or dependent’s coverage described in item (1) of this subsection:
(i)    was under a COBRA continuation provision, and the coverage under that provision was exhausted; or
(ii)    was not under a COBRA continuation provision, and either the coverage was terminated as a result of loss of eligibility for the coverage, including loss of eligibility as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment, or employer contributions towards the coverage were terminated; and
(4)    under the terms of the plan, the employee requests enrollment not later than 30 days after:
(i)    the date of exhaustion of coverage described in item (3)(i) of this subsection; or
(ii)    termination of coverage or termination of employer contributions described in item (3)(ii) of this subsection.
(e)    A carrier shall allow an employee or dependent who is eligible, but not enrolled, for coverage under the terms of a group health benefit plan to enroll for coverage under the terms of the plan if the employee or dependent requests enrollment within 30 days after the employee or dependent is determined to be eligible for coverage under the MCHP private option plan in accordance with § 15-301.1 of the Health - General Article.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 14 - Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms › Section 15-1406.1 - Enrollment of Dependents

(a)    In this section, “eligible employee” means:
(1)    a participant under the group health benefit plan; or
(2)    an individual who:
(i)    has met any waiting period applicable to becoming a participant under the group health benefit plan;
(ii)    is eligible to be enrolled under the plan; and
(iii)    is not a participant in the group health benefit plan because of failure to enroll during a previous enrollment period.
(b)    This section applies if a group health benefit plan makes coverage available to dependents of an eligible employee.
(c)    A group health benefit plan subject to this section shall provide a special enrollment period during which the following individuals may be enrolled under the group health benefit plan:
(1)    an individual who becomes a dependent of an eligible employee through marriage, birth, adoption, or placement for adoption;
(2)    an eligible employee who acquires a new dependent through marriage, birth, adoption, or placement for adoption; and
(3)    the spouse of an eligible employee at the birth or adoption of a child, provided the spouse is otherwise eligible for coverage.
(d)    An eligible employee may not enroll a dependent during a special enrollment period unless the eligible employee:
(1)    is enrolled under the health benefit plan; or
(2)    applies for coverage for the eligible employee during the same special enrollment period.
(e)    The special enrollment period under subsection (c) of this section shall be a period of not less than 31 days and shall begin on the later of:
(1)    the date dependent coverage is made available; or
(2)    the date of the marriage, birth, adoption, or placement for adoption, whichever is applicable.
(f)    If an eligible employee enrolls any of the individuals described in subsection (c) of this section during the first 31 days of the special enrollment period, the coverage shall become effective as follows:
(1)    in the case of marriage, not later than the first day of the first month beginning after the date the completed request for enrollment is received;
(2)    in the case of a dependent’s birth, as of the date of the dependent’s birth; and
(3)    in the case of a dependent’s adoption or placement for adoption, the date of adoption or placement for adoption, whichever occurs first.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 14 - Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms › Section 15-1407 - Premiums Based on Health Status-Related Factors

A carrier may not require an individual member of a group to pay a premium or contribution that is greater than the premium or contribution for a similarly situated individual, based on any health status-related factor.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 14 - Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms › Section 15-1408 - Renewal of Group Health Benefit Plan

A carrier shall renew group health benefit plans at the option of the policyholder or plan sponsor, except in any of the following cases:
(1)    for nonpayment of the required premium;
(2)    where the policyholder or plan sponsor has performed an act or practice that constitutes fraud;
(3)    where the policyholder or plan sponsor has made an intentional misrepresentation of material fact under the terms of the coverage;
(4)    where the policyholder or plan sponsor has failed to comply with a material plan provision relating to the employer contributions or group participation rules;
(5)    where the carrier elects not to renew all group health benefit plans in the State;
(6)    in the case of a health maintenance organization, where there is no longer any enrollee who lives, resides, or works in the health maintenance organization’s approved service area, provided notice of the nonrenewal is provided to each employer and to each employee covered under the health benefit plan at least 90 days before the date coverage will be terminated;
(7)    in the case of a carrier that offers coverage only through one or more bona fide associations, when the membership of an employer in the association ceases and nonrenewal under this item is applied uniformly without regard to any health status–related factor relating to any covered individual; or
(8)    the carrier makes an election under § 15–1409 of this subtitle.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 14 - Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms › Section 15-1409 - Nonrenewal of Plans

(a)    In this section, “product” means a discrete package of health benefits that are offered using a particular product network type within a geographic service area.
(b)    A carrier that elects not to renew all of a particular product in the State shall:
(1)    provide notice of the nonrenewal at least 90 days before the date of the nonrenewal to each affected:
(i)    policyholder;
(ii)    plan sponsor;
(iii)    participant; and
(iv)    beneficiary;
(2)    offer to each affected plan sponsor the option to purchase any other health insurance coverage currently being offered by the carrier; and
(3)    act uniformly without regard to the claims experience of any affected plan sponsor, or any health status–related factor of any affected individual.
(c)    A carrier may elect not to renew all group health benefit plans in the State.
(d)    When a carrier elects not to renew all group health benefit plans in the State, the carrier:
(1)    shall give notice of its decision to the affected individuals at least 180 days before the effective date of nonrenewal;
(2)    at least 30 working days before that notice, shall give notice to the Commissioner; and
(3)    may not write new business for groups in the State for a 5–year period beginning on the date of notice to the Commissioner.
(e)    A health maintenance organization need not offer coverage to an individual who does not live, reside, or work within the health maintenance organization’s approved service areas.
(f)    A carrier may make a uniform modification of coverage for a product only at the time of renewal of a health benefit plan.
(g)    A carrier will not be considered to have elected not to renew all group health benefit plans in the State if the carrier complies with 45 C.F.R. § 147.106(d)(3).
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 14 - Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms › Section 15-1410 - Applicability of Affordable Care Act Provisions

(a)    In this section, “plan year” has the meaning stated in § 15–1201 of this title.
(b)    The guaranteed issuance of coverage provision in Title I, Subtitle C of the Affordable Care Act applies to each health benefit plan with a plan year that begins on or after January 1, 2014.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 14 - Maryland Health Insurance Portability and Accountability Act -- Large Group Market Reforms › Section 15-1411 - Disclosure of Aggregate Incurred Claims

(a)    (1)    In this section the following words have the meanings indicated.
(2)    “Aggregate incurred claims” means the total claims incurred in the experience period that the carrier uses to experience rate a large employer’s health benefit plan.
(3)    “Experience rating” means that a carrier develops the premium rates for an employer’s health benefit plan based in whole or in part on the claims experience of the group that consists of the employer’s employees or employees’ dependents.
(4)    “Large employer” means an employer that is not a small employer as defined in § 31–101 of this article.
(b)    If a carrier is experience rating a large employer’s health benefit plan, the carrier shall disclose the aggregate incurred claims of the group to the large employer within 30 days after receipt of a request from the large employer.
(c)    The aggregate incurred claims required to be disclosed under subsection (b) of this section shall be provided in a format that complies with the privacy requirements of the federal Health Insurance Portability and Accessibility Act.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 15 - Mandated Health Insurance Services Evaluation › Section 15-1502 - Evaluation of Mandated Health Insurance Services

(a)    (1)    The Commission shall conduct an evaluation of existing mandated health insurance services and make recommendations to the General Assembly regarding decision making criteria for reducing the number of mandates or the extent of coverage.
(2)    The evaluation shall include:
(i)    an assessment of the full cost of each existing mandated health insurance service as a percentage of the State’s average annual wage and of premiums:
1.    under a typical group and individual health benefit plan in the State;
2.    under the State employee health benefit plan; and
3.    under the Comprehensive Standard Health Benefit Plan;
(ii)    an assessment of the degree to which existing mandated health insurance services are covered in self–funded plans; and
(iii)    a comparison of mandated health insurance services provided by the State with those provided in Delaware, the District of Columbia, Pennsylvania, and Virginia.
(3)    The comparison described in paragraph (2)(iii) of this subsection shall include:
(i)    the number of mandated health insurance services;
(ii)    the type of mandated health insurance services;
(iii)    the level and extent of coverage for each mandated health insurance service; and
(iv)    the financial impact of differences in levels of coverage for each mandated health insurance service.
(4)    On or before January 1, 2004, and every 4 years thereafter, the Commission shall submit a report of its findings to the General Assembly, subject to § 2–1257 of the State Government Article.
(b)    The General Assembly may consider the information provided under subsection (a) of this section in determining:
(1)    whether to enact proposed mandated health insurance services; and
(2)    whether to repeal existing mandated health insurance services.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part II - Registration and Regulation of Pharmacy Benefits Managers › Section 15-1604 - Registration

(a)    A pharmacy benefits manager shall register with the Commissioner as a pharmacy benefits manager before providing pharmacy benefits management services in the State to purchasers.
(b)    An applicant for registration shall:
(1)    file with the Commissioner an application on the form that the Commissioner provides; and
(2)    pay to the Commissioner a registration fee set by the Commissioner.
(c)    The Commissioner may require any additional information or submissions from a pharmacy benefits manager that may be reasonably necessary to verify the information contained in the application.
(d)    Subject to the provisions of § 15–1607 of this part, the Commissioner shall register each pharmacy benefits manager that meets the requirements of this section.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part II - Registration and Regulation of Pharmacy Benefits Managers › Section 15-1605 - Expiration; Renewal

(a)    A pharmacy benefits manager registration expires on the second September 30 after its effective date unless it is renewed as provided under this section.
(b)    A pharmacy benefits manager may renew its registration for an additional 2–year term, if the pharmacy benefits manager:
(1)    otherwise is entitled to be registered;
(2)    files with the Commissioner a renewal application on the form that the Commissioner requires; and
(3)    pays to the Commissioner a renewal fee set by the Commissioner.
(c)    An application for renewal of a pharmacy benefits manager registration shall be considered made in a timely manner if it is postmarked on or before the date the pharmacy benefits manager’s registration expires.
(d)    Subject to the provisions of § 15–1607 of this part, the Commissioner shall renew the registration of each pharmacy benefits manager that meets the requirements of this section.
(e)    The Commissioner may require any additional information or submissions from a pharmacy benefits manager that may be reasonably necessary to verify the information contained in the application.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part II - Registration and Regulation of Pharmacy Benefits Managers › Section 15-1607 - Denials, Suspensions, Revocations, and Refusals to Renew

(a)    Subject to the applicable hearing provisions of Title 2 of this article, the Commissioner may deny a registration to a pharmacy benefits manager applicant or refuse to renew, suspend, or revoke the registration of a pharmacy benefits manager if the pharmacy benefits manager, or an officer, director, or employee of the pharmacy benefits manager:
(1)    makes a material misstatement or misrepresentation in an application for registration;
(2)    fraudulently or deceptively obtains or attempts to obtain a registration;
(3)    in connection with the administration of pharmacy benefits management services, commits fraud or engages in illegal or dishonest activities; or
(4)    violates any provision of this part or a regulation adopted under this part.
(b)    This section does not limit any other regulatory authority of the Commissioner under this article.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part II - Registration and Regulation of Pharmacy Benefits Managers › Section 15-1608 - Books and Records

A pharmacy benefits manager shall maintain adequate books and records about each purchaser for which the pharmacy benefits manager provides pharmacy benefits management services:
(1)    in accordance with prudent standards of record keeping;
(2)    for the duration of the agreement between the pharmacy benefits manager and the purchaser; and
(3)    for 3 years after the pharmacy benefits manager ceases to provide pharmacy benefits management services for the purchaser.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part II - Registration and Regulation of Pharmacy Benefits Managers › Section 15-1609 - Examinations

(a)    Whenever the Commissioner considers it advisable, the Commissioner may examine the affairs, transactions, accounts, and records of a registered pharmacy benefits manager.
(b)    The examination shall be conducted in accordance with § 2–207 of this article.
(c)    The expense of the examination shall be paid in accordance with § 2–208 of this article.
(d)    The reports of the examination and investigation shall be issued in accordance with § 2–209 of this article.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part II - Registration and Regulation of Pharmacy Benefits Managers › Section 15-1610 - Delivery Through Nonresident Pharmacies

A pharmacy benefits manager may not ship, mail, or deliver prescription drugs or devices to a person in the State through a nonresident pharmacy unless the nonresident pharmacy holds a permit issued in accordance with the provisions of § 12–403 of the Health Occupations Article.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part II - Registration and Regulation of Pharmacy Benefits Managers › Section 15-1611 - Information on and Sales of Prescription Drugs

(a)    This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)    A pharmacy benefits manager may not prohibit a pharmacy or pharmacist from:
(1)    providing a beneficiary with information regarding the retail price for a prescription drug or the amount of the cost share for which the beneficiary is responsible for a prescription drug;
(2)    discussing with a beneficiary information regarding the retail price for a prescription drug or the amount of the cost share for which the beneficiary is responsible for a prescription drug; or
(3)    if a more affordable drug is available than one on the purchaser’s formulary and the requirements for a therapeutic interchange under §§ 15–1633.1 through 15–1639 of this subtitle are met, selling the more affordable alternative to the beneficiary.
(c)    This section may not be construed to alter the requirements for a therapeutic interchange under §§ 15–1633.1 through 15–1639 of this subtitle.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part II - Registration and Regulation of Pharmacy Benefits Managers › Section 15-1611.1 - Choice of Pharmacy by Beneficiary to Fill Prescription

(a)    This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)    Except as provided in subsection (c) of this section, a pharmacy benefits manager may not require that a beneficiary use a specific pharmacy or entity to fill a prescription if:
(1)    the pharmacy benefits manager or a corporate affiliate of the pharmacy benefits manager has an ownership interest in the pharmacy or entity; or
(2)    the pharmacy or entity has an ownership interest in the pharmacy benefits manager or a corporate affiliate of the pharmacy benefits manager.
(c)    A pharmacy benefits manager may require a beneficiary to use a specific pharmacy or entity for a specialty drug as defined in § 15–847 of this title.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part II - Registration and Regulation of Pharmacy Benefits Managers › Section 15-1612 - Reimbursement for Pharmaceutical Product or Pharmacist Service

(a)    This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)    This section does not apply to reimbursement:
(1)    for specialty drugs;
(2)    for mail order drugs; or
(3)    to a chain pharmacy with more than 15 stores or a pharmacist who is an employee of the chain pharmacy.
(c)    A pharmacy benefits manager may not reimburse a pharmacy or pharmacist for a pharmaceutical product or pharmacist service in an amount less than the amount that the pharmacy benefits manager reimburses itself or an affiliate for providing the same product or service.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part III - Pharmacy and Therapeutics Committees › Section 15-1614 - Composition; Conflict of Interest Statement

(a)    (1)    A pharmacy and therapeutics committee shall:
(i)    include clinical specialists that represent the needs of a purchaser’s beneficiaries; and
(ii)    include at least one practicing pharmacist and one practicing physician who are independent of any developer or manufacturer of prescription drugs.
(2)    A majority of the members of a pharmacy and therapeutics committee shall be practicing physicians or practicing pharmacists.
(b)    Each member of a pharmacy and therapeutics committee shall sign a conflict of interest statement updated at least annually disclosing any economic interest or relationship that could influence the pharmacy and therapeutics committee’s decisions.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part III - Pharmacy and Therapeutics Committees › Section 15-1617 - Required Policies, Procedures, and Processes

A pharmacy benefits manager shall ensure that its pharmacy and therapeutics committee has:
(1)    policies and procedures, including disclosure requirements, to address potential conflicts of interest that members of the pharmacy and therapeutics committee may have with developers or manufacturers of prescription drugs;
(2)    a process to evaluate medical and scientific evidence concerning the safety and effectiveness of prescription drugs, including available comparative information on clinically similar prescription drugs, when deciding what prescription drugs to recommend to include on a formulary;
(3)    a process to evaluate medical and scientific evidence concerning the safety and effectiveness of prescription drugs when recommending utilization review requirements, dose restrictions, and step therapy requirements; and
(4)    a process to enable the pharmacy and therapeutics committee to consider the need to recommend a formulary change to a purchaser in a timely manner but at least annually.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part III - Pharmacy and Therapeutics Committees › Section 15-1618 - Accreditation

The Commissioner may consider a pharmacy and therapeutics committee of a pharmacy benefits manager as having met the requirements of §§ 15–1614 and 15–1617 of this part if the pharmacy benefits manager has obtained accreditation from an accrediting organization approved by the Commissioner.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part IV - Disclosures to Purchasers › Section 15-1622 - Scope of Part

(a)    Except as provided for in subsection (b) of this section, the provisions of §§ 15–1623 and 15–1624 of this subtitle apply only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)    The provisions of §§ 15–1623 and 15–1624 of this part do not apply to a pharmacy benefits manager when providing pharmacy benefits management services to a purchaser that is affiliated with the pharmacy benefits manager through common ownership within an insurance holding company.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part IV - Disclosures to Purchasers › Section 15-1623 - Requirements Before Entering Into Contract

(a)    Before entering into a contract with a purchaser, a pharmacy benefits manager:
(1)    as applicable, shall inform the purchaser that the pharmacy benefits manager may:
(i)    solicit and receive manufacturer payments;
(ii)    pass through or retain the manufacturer payments depending on the contract terms with a purchaser;
(iii)    sell aggregate utilization information; and
(iv)    share aggregate utilization information with other entities; and
(2)    shall offer to provide to the purchaser a report that contains the:
(i)    net revenue of the pharmacy benefits manager from sales of prescription drugs to purchasers made through the pharmacy benefits manager’s network of contractually affiliated retail pharmacies or through the pharmacy benefits manager’s mail order pharmacies, with respect to the pharmacy benefits manager’s entire client base of purchasers; and
(ii)    amount of all manufacturer payments earned by the pharmacy benefits manager.
(b)    (1)    If a purchaser requests the information described in subsection (a)(2) of this section, a pharmacy benefits manager shall provide the information before entering into a contract with the purchaser.
(2)    Notwithstanding the provisions of paragraph (1) of this subsection, if a pharmacy benefits manager requires a nondisclosure agreement under which a purchaser agrees that the information described in subsection (a)(2) of this section is proprietary information, the pharmacy benefits manager may not be required to provide the information until the purchaser has signed the nondisclosure agreement.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part IV - Disclosures to Purchasers › Section 15-1624 - Rebate Sharing Contract

(a)    If a purchaser has a rebate sharing contract, a pharmacy benefits manager shall offer to provide the purchaser a report for each fiscal quarter and each fiscal year that contains the amount of the:
(1)    net revenue of the pharmacy benefits manager from sales of prescription drugs to purchasers made through the pharmacy benefits manager’s network of contractually affiliated retail pharmacies or through the pharmacy benefits manager’s mail order pharmacies, with respect to the pharmacy benefits manager’s entire client base of purchasers;
(2)    total prescription drug expenditures applicable to the purchaser;
(3)    total manufacturer payments earned by the pharmacy benefits manager during the applicable reporting period; and
(4)    total rebates applicable to the purchaser during the applicable reporting period.
(b)    If the exact amount of each item to be reported under subsection (a) of this section is not known by the pharmacy benefits manager at the time of its report, the pharmacy benefits manager shall offer to provide:
(1)    its current best estimate of the amount of each item; and
(2)    an updated report containing the exact amount of each item immediately after it becomes available.
(c)    (1)    A pharmacy benefits manager shall provide the information described in subsections (a) and (b) of this section if requested by the purchaser.
(2)    Notwithstanding the provisions of paragraph (1) of this subsection, if a pharmacy benefits manager requires a nondisclosure agreement under which a purchaser agrees that the information in subsections (a) and (b) of this section is proprietary information, the pharmacy benefits manager may not be required to provide the information until the purchaser has signed the nondisclosure agreement.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part V - Contracts With Pharmacies and Pharmacists; Audits › Section 15-1628.3 - Fee or Performance-Based Reimbursement Related to Claim Adjudication

(a)    A pharmacy benefits manager or a carrier may not directly or indirectly charge a contracted pharmacy, or hold a contracted pharmacy responsible for, a fee or performance–based reimbursement related to the adjudication of a claim or an incentive program.
(b)    A pharmacy benefits manager or carrier may not make or allow any reduction in payment for pharmacy services by a pharmacy benefits manager or carrier or directly or indirectly reduce a payment for a pharmacy service under a reconciliation process to an effective rate of reimbursement, including generic effective rates, brand effective rates, direct and indirect remuneration fees, or any other reduction or aggregate reduction of payments.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part V - Contracts With Pharmacies and Pharmacists; Audits › Section 15-1630 - Internal Review Process

(a)    This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
(b)    A pharmacy benefits manager shall establish a reasonable internal review process for a pharmacy to request the review of a failure to pay the contractual reimbursement amount of a submitted claim.
(c)    A pharmacy may request a pharmacy benefits manager to review a failure to pay the contractual reimbursement amount of a claim within 180 calendar days after the date the submitted claim was paid by the pharmacy benefits manager.
(d)    The pharmacy benefits manager shall give written notice of its review decision within 90 calendar days after receipt of a request for review from a pharmacy under this section.
(e)    If the pharmacy benefits manager determines through the internal review process established under subsection (b) of this section that the pharmacy benefits manager underpaid a pharmacy, the pharmacy benefits manager shall pay any money due to the pharmacy within 30 working days after completion of the internal review process.
(f)    This section may not be construed to limit the ability of a pharmacy and a pharmacy benefits manager to contractually agree that a pharmacy may have more than 180 calendar days to request an internal review of a failure of the pharmacy benefits manager to pay the contractual amount of a submitted claim.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part V - Contracts With Pharmacies and Pharmacists; Audits › Section 15-1631 - Retroactive Denial or Modification of Reimbursement for Approved Claim

Except for an overpayment as defined in § 15–1629(h) of this subtitle, if a claim has been approved by a pharmacy benefits manager through adjudication, the pharmacy benefits manager may not retroactively deny or modify reimbursement to a pharmacy or pharmacist for the approved claim unless:
(1)    the claim was fraudulent;
(2)    the pharmacy or pharmacist had been reimbursed for the claim previously; or
(3)    the services reimbursed were not rendered by the pharmacy or pharmacist.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part VI - Therapeutic Interchanges › Section 15-1633 - Application of Provisions to Certain Pharmacy Benefits Managers

A pharmacy benefits manager or its agent may not request a therapeutic interchange unless:
(1)    the proposed therapeutic interchange is for medical reasons that benefit the beneficiary; or
(2)    the proposed therapeutic interchange will result in financial savings and benefits to the purchaser or the beneficiary.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part VI - Therapeutic Interchanges › Section 15-1634 - Authorization; Disclosures; Money-Saving Claims; Payment for Interchange

(a)    Before making a therapeutic interchange, a pharmacy benefits manager or its agent shall obtain authorization from a prescriber or an individual authorized by the prescriber.
(b)    In any therapeutic interchange solicitation, the following shall be disclosed to the prescriber:
(1)    that a therapeutic interchange is being solicited;
(2)    the circumstances under which the originally prescribed drug will be covered by the purchaser;
(3)    the difference in copayments or coinsurance to be paid by the beneficiary to obtain the proposed drug;
(4)    the circumstances and extent to which health care costs related to the therapeutic interchange will be compensated; and
(5)    any clinically significant differences, as determined by a pharmacy and therapeutics committee of the pharmacy benefits manager, with respect to efficacy, side effects, and potential impact on health and safety.
(c)    When soliciting a therapeutic interchange from a prescriber, a pharmacy benefits manager or its agent may not make a claim that the therapeutic interchange will save the purchaser money unless the claim can be substantiated.
(d)    If the pharmacy benefits manager or its agent receives payment for making a therapeutic interchange from a pharmaceutical manufacturer or other person, including the pharmacy benefits manager, that is not reflected in cost savings to the purchaser, the existence of the payment shall be communicated to the prescriber at the time of the therapeutic interchange solicitation.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part VI - Therapeutic Interchanges › Section 15-1635 - Requirements When Interchange Occurs

If a therapeutic interchange occurs, the pharmacy benefits manager or its agent shall:
(1)    disclose to the beneficiary, orally or in writing:
(i)    that the pharmacy benefits manager or its agent requested a therapeutic interchange by contacting the beneficiary’s prescriber;
(ii)    the prescriber approved the therapeutic interchange;
(iii)    the names of the originally prescribed drug and the drug dispensed pursuant to the therapeutic interchange;
(iv)    the difference in copayments or coinsurance to be paid by the beneficiary to obtain the drug dispensed pursuant to the therapeutic interchange;
(v)    the circumstances under which the originally prescribed drug will be covered;
(vi)    the circumstances under and the extent to which health care costs related to the therapeutic interchange will be compensated; and
(vii)    that the beneficiary may decline the therapeutic interchange if the originally prescribed drug remains on the beneficiary’s formulary, and the beneficiary is willing to pay any difference in the copayment or coinsurance; and
(2)    include with the prescription drug dispensed:
(i)    a patient package insert about potential side effects; and
(ii)    a toll–free telephone number to communicate with the pharmacy benefits manager.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part VI - Therapeutic Interchanges › Section 15-1636 - Cancellation and Reversal

(a)    A pharmacy benefits manager or its agent shall cancel and reverse a therapeutic interchange on written or verbal instructions from a prescriber, the beneficiary, or the beneficiary’s representative.
(b)    If a therapeutic interchange is reversed, the pharmacy benefits manager or its agent shall:
(1)    obtain a prescription for and dispense the originally prescribed prescription drug; and
(2)    charge the beneficiary no more than one copayment.
(c)    If the therapeutic interchange occurred through a mail order pharmacy and a beneficiary will exhaust an existing supply of the originally prescribed prescription drug before a replacement shipment will arrive to the beneficiary, the pharmacy benefits manager or its agent shall arrange for dispensing of an appropriate quantity of replacement prescription drugs at a local community pharmacy at no additional cost to the beneficiary.
(d)    A pharmacy benefits manager or its agent may not be required to cancel and reverse a therapeutic interchange if a beneficiary is unwilling to pay a higher copayment or coinsurance associated with the originally prescribed prescription drug.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 16 - Pharmacy Benefits Managers › Part VI - Therapeutic Interchanges › Section 15-1637 - Maintenance of Toll-Free Telephone Number

(a)    A pharmacy benefits manager shall maintain a toll–free telephone number Monday through Saturday for prescribers, pharmacies, pharmacists, and beneficiaries to request information regarding a therapeutic interchange.
(b)    The toll–free telephone number shall be accessible from 8 a.m. until at least 8 p.m. Eastern Standard Time.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 17 - Regulation of Physician Rating Systems › Section 15-1701 - Definitions

(a)    In this subtitle the following words have the meanings indicated.
(b)    “Carrier” has the meaning stated in § 15–1301 of this title.
(c)    “Enrollee” means an individual entitled to health care benefits from a carrier.
(d)    “Physician rating system” means any program that:
(1)    measures, rates, or tiers the performance of physicians under contract with the carrier; and
(2)    discloses the measures, rates, or tiers to enrollees or the public.
(e)    “Ratings examiner” means an independent entity that is approved by the Maryland Health Care Commission to review physician rating systems.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 17 - Regulation of Physician Rating Systems › Section 15-1702 - General Consideration

(a)    A carrier may not use a physician rating system unless the physician rating system is approved by a ratings examiner.
(b)    A carrier shall contract with and pay for a ratings examiner to review any physician rating system of the carrier.
(c)    A physician rating system of a carrier is deemed to meet the requirements of this section if the physician rating system:
(1)    is approved by a ratings examiner as of January 1, 2010; and
(2)    notwithstanding any revisions to the physician rating system, maintains its approval by the ratings examiner.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 17 - Regulation of Physician Rating Systems › Section 15-1703 - Appeals Process

(a)    A carrier that uses a physician rating system shall:
(1)    establish an appeals process for physicians to use to contest their rating; and
(2)    at least 45 days before making available to enrollees any new or revised quality of performance or  cost–efficiency evaluations or any new or revised inclusions or exclusions from a physician rating system, provide each physician included in the physician rating system with:
(i)    a notice of the proposed change;
(ii)    an explanation of the data used to assess the physician and how the physician may access the data;
(iii)    the methodology and measures used to assess the physician;
(iv)    an explanation of the right to contest the rating of the physician through the appeals process of the carrier; and
(v)    instructions on how to file a timely appeal with the carrier.
(b)    If a physician files a timely appeal, as defined by the carrier, regarding the rating of the physician under a physician rating system, the carrier may not disclose the rating of the physician or make a change in the quality of performance or  cost–efficiency ratings of the physician until the carrier completes its investigation and renders a decision on the appeal.
(c)    A carrier shall post the following information prominently on the section of the carrier’s Web site that discloses the rating of a physician to enrollees or to the public:
(1)    where an enrollee can find the physician performance ratings of the carrier;
(2)    a disclosure that physician performance ratings are only a guide to choosing a physician because the ratings have a risk of error and should not be the sole basis for selecting a physician;
(3)    an explanation of the physician rating system, including the basis on which physician performance is measured and the basis for determining that a physician is not currently rated due to insufficient data or a pending appeal;
(4)    any limitations of the data that the carrier uses to measure physician performance;
(5)    the factors and criteria used in the carrier’s physician rating system, including quality of performance measures and cost efficiency measures; and
(6)    how a physician may appeal a physician rating.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 17 - Regulation of Physician Rating Systems › Section 15-1704 - Notification of Results of Review; Finding of Noncompliance; Reports

(a)    A carrier shall notify the Commissioner of the results of any final review conducted by a ratings examiner of a physician rating system of the carrier within 45 calendar days after receipt of the results by the carrier.
(b)    If the review conducted by a ratings examiner of a physician rating system of a carrier indicates that the physician rating system does not comply with the requirements of Title 19, Subtitle 1, Part V of the Health – General Article, the Commissioner may order the carrier to:
(1)    correct the deficiency; or
(2)    cease the use of the physician rating system.
(c)    A carrier using a physician rating system shall report annually to the Commissioner:
(1)    the number of appeals filed by physicians under this subtitle; and
(2)    the outcome of the appeals.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 19 - Clinically Integrated Organizations › Section 15-1901 - Definitions

(a)    In this subtitle the following words have the meanings indicated.
(b)    “Carrier” means:
(1)    an insurer;
(2)    a nonprofit health service plan; or
(3)    a health maintenance organization.
(c)    “Clinically integrated organization” means:
(1)    a joint venture between a hospital and physicians that:
(i)    has received an advisory opinion from the Federal Trade Commission or its staff; and
(ii)    has been established to:
1.    evaluate and improve the practice patterns of the health care providers; and
2.    create a high degree of cooperation, collaboration, and mutual interdependence among the health care providers who participate in the joint venture in order to promote the efficient, medically appropriate delivery of covered medical services; or
(2)    a joint venture between a hospital and physicians that:
(i)    is accountable for total spending and quality; and
(ii)    the Commissioner determines meets the criteria established by the federal Department of Health and Human Services for an accountable care organization.
(d)    “Covered medical services” means the health care services that are included as benefits under a health benefit plan issued by a carrier.
(e)    “Health benefit plan” has the meaning stated in  § 15–1301 of this title.
(f)    “Qualifying individual” means an individual covered under a health benefit plan issued by a carrier.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 19 - Clinically Integrated Organizations › Section 15-1902 - Contract Between Carrier and a Clinically Integrated Organization

(a)    Notwithstanding any other provision of this article or the Health – General Article, a contract between a carrier and a clinically integrated organization may include a provision to pay:
(1)    for services associated with the coordination of covered medical services to qualifying individuals; and
(2)    a bonus, fee–based incentive, bundled fees, or other incentives to promote the efficient, medically appropriate delivery of covered medical services to qualifying individuals.
(b)    The Commissioner, in consultation with the Maryland Health Care Commission, may adopt regulations specifying the types of payments and incentives permissible under this section.
(c)    (1)    A carrier shall file a copy of a contract between the carrier and a clinically integrated organization with the Commissioner.
(2)    If the contract includes a provision to pay a bonus or other incentive that does not comply with § 15–113 of this title, the Commissioner shall provide a copy of the contract to the executive director of the Maryland Health Care Commission.
(3)    Notwithstanding any other provision of law, a copy of a contract filed with the Commissioner or provided by the Commissioner to the executive director of the Maryland Health Care Commission under this subsection, is:
(i)    confidential and privileged;
(ii)    not subject to:
1.    Title 4 of the General Provisions Article;
2.    subpoena; or
3.    discovery; and
(iii)    not admissible in evidence in any private action.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 19 - Clinically Integrated Organizations › Section 15-1903 - Sharing Medical Information

Notwithstanding any other provision of this article or the Health – General Article, a carrier shall share medical information about a qualifying individual with a clinically integrated organization and its members if:
(1)    the carrier has a written agreement with the clinically integrated organization specifying the type and proposed use of medical information to be shared;
(2)    the medical information is used by the clinically integrated organization to:
(i)    promote the efficient, medically appropriate delivery of covered medical services to qualifying individuals;
(ii)    coordinate care, including efforts to coordinate, plan, develop, monitor, share information related to, and otherwise initiate a treatment plan for a qualifying individual;
(iii)    perform the functions of a medical review committee as described in § 1–401(c) of the Health Occupations Article; or
(iv)    offer or provide covered medical services or seek payment for or evaluate covered medical services provided by the members of the clinically integrated organization; and
(3)    the clinically integrated organization or the carrier implements procedures for disclosing to qualifying individuals how the clinically integrated organization and the carrier share medical information to deliver more coordinated, higher quality care.