reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.18 - Denials of Coverage Based on Medical Necessity › Section 31.10.18.11 - Demonstration of Compelling Reason to File Complaint

Current through Register Vol. 51, No. 14, July 12, 2024
A. A member, a member's representative, or a health care provider on behalf of a member may file a complaint without first exhausting the internal grievance process of a carrier if the complaint demonstrates to the satisfaction of the Commissioner a compelling reason to do so. A compelling reason includes showing that the potential delay in receipt of a health care service until after the member or health care provider exhausts the internal grievance process and obtains a final decision under the grievance process could result in:
(1) Loss of life
(2) Serious impairment to a bodily function
(3) Serious dysfunction of a bodily organ;
(4) The member remaining seriously mentally ill or using intoxicating substances with symptoms that cause the member to be in danger to self or others; or
(5) The member continuing to experience severe withdrawal symptoms.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.18 - Denials of Coverage Based on Medical Necessity › Section 31.10.18.12 - General Procedures for Complaints

Current through Register Vol. 51, No. 14, July 12, 2024
A. Consent Form.
(1) For services rendered on or after January 1, 1999, the Commissioner shall request the signed consent of the member that filed the complaint, or a legally authorized designee of the member, authorizing the release of the member's medical records to the Commissioner or the Commissioner's designee that are needed in order for the Commissioner to make a final decision on the complaint.
(2) The Commissioner may refuse to investigate a complaint if the member or legally authorized designee of the member fails to sign a consent form.
(3) In the case of alcohol and drug abuse, the member shall deliver the member's medical records to the Health Advocacy Unit or to the Commissioner, or to both, pursuant to federal law and regulations.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.19 - Independent Review Organizations and Medical Experts › Section 31.10.19.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) Adverse Decision.
(a) "Adverse decision" means a utilization review determination by a private review agent, a carrier, or a health care provider acting on behalf of a carrier that:
(i) A proposed or delivered health care service that is otherwise covered under the member's contract is not or was not medically necessary, appropriate, or efficient; and
(ii) May result in noncoverage of the health care service.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.19 - Independent Review Organizations and Medical Experts › Section 31.10.19.02 - Use of Independent Review Organizations and Medical Experts

Current through Register Vol. 51, No. 14, July 12, 2024
A. In cases considered appropriate by the Commissioner, the Commissioner shall seek advice concerning adverse decisions from an independent review organization or medical expert, as provided in Insurance Article, § 15-10 A-05, Annotated Code of Maryland.
B. For any independent review organization or medical expert that contracts with the Commissioner, the independent review organization or medical expert shall have a quality assurance mechanism in place that assures the:
(1) Timeliness and quality of the reviews;
(2) Qualifications and independence of the expert reviewers and the independent review organization, or the medical expert; and
(3) Confidentiality of medical records and review materials, consistent with federal and State laws.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.19 - Independent Review Organizations and Medical Experts › Section 31.10.19.03 - Conflicts of Interest Standards for Independent Review Organizations and Medical Experts

Current through Register Vol. 51, No. 14, July 12, 2024
A. An independent review organization or medical expert may not be an affiliate of a trade association of:
(1) Health benefit plans; or
(2) Health care providers.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.19 - Independent Review Organizations and Medical Experts › Section 31.10.19.04 - Assignment of an Independent Review Organization or Medical Expert

Current through Register Vol. 51, No. 14, July 12, 2024
A. Concurrently with the assignment of a complaint to an independent review organization or a medical expert, the Commissioner shall notify the member, member's representative, or health care provider acting on behalf of the member, and the carrier of the assignment.
B. If the complaint is assigned to an independent review organization, the independent review organization shall screen its expert reviewer for potential material conflicts of interest.
C. The Commissioner shall have the discretion to determine whether a material conflict of interest exists for the expert reviewer of an independent review organization or the medical experts subject to this regulation and as provided by Insurance Article, § 15-10 A-05, Annotated Code of Maryland.
D. An expert reviewer or medical expert shall:
(1) Be an expert in the treatment of the member's specific medical condition;
(2) Be knowledgeable about the recommended health care service or treatment through actual clinical experience as determined by the Commissioner based on the period of time:
(a) Actually treating patients with the same or similar specific medical condition, and
(b) That has elapsed between the clinical experience and the present;
(3) Hold:
(a) A nonrestricted license as a physician or other appropriate health care provider in a state of the United States; and
(b) For physicians, a current certification by a recognized American Medical Specialty Board in the area appropriate to the subject of review;
(4) Be licensed in the same health care occupation as the health care provider who considers the health care service that is the subject of the carrier's adverse decision to be medically necessary, appropriate, or efficient; and
(5) Have no history of disciplinary investigations, actions, or sanctions, including loss of staff privileges or participation restrictions that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body, that raises a substantial question as to the expert reviewer's or medical expert's physical, mental or professional competence or moral character as determined by the Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.19 - Independent Review Organizations and Medical Experts › Section 31.10.19.05 - Independent Review

Current through Register Vol. 51, No. 14, July 12, 2024
A. In conducting a review of an adverse decision, each independent review organization or medical expert shall, after reviewing all relevant medical and contractual information, advise the Commissioner in writing on whether the service was medically necessary.
B. The advice to the Commissioner shall state in writing the specific factual bases for the decision of the expert reviewer or the medical expert and reference the specific criteria and standards, including interpretive guidelines, on which the expert reviewer's or the medical expert's decision was based.
C. The Commissioner shall preserve the confidentiality of commercial information and a member's medical records and personal records in accordance with:
(1) State Government Article, §
										10-611 et seq., Annotated Code of Maryland;
(2) Health-General Article, §4-301, Annotated Code of Maryland; and
(3) Any pertinent federal laws.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.19 - Independent Review Organizations and Medical Experts › Section 31.10.19.06 - Payment of Fees

Current through Register Vol. 51, No. 14, July 12, 2024
A. The carrier that is the subject of the complaint is responsible for paying the reasonable expenses for the complaint under review by the independent review organization or medical expert selected by the Commissioner.
B. The independent review organization or medical expert for each complaint under review shall:
(1) Present to the carrier:
(a) An invoice detailing the expenses incurred by the independent review organization or medical expert related to the complaint under review, and
(b) Any other information required in the event that the contract between the independent review organization or the medical expert and the Commissioner requires a flat fee; and
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.19 - Independent Review Organizations and Medical Experts › Section 31.10.19.07 - Time for Rendering Final Decisions on Complaints

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except for an emergency case as provided in COMAR 31.10.18.05B or as provided in §B of this regulation, the Commissioner shall make a final written decision on a complaint within 45 days after a complaint is filed.
B. The Commissioner may extend the period within which a final written decision is to be made under §A of this regulation for up to an additional 30 working days if the:
(1) Commissioner has not yet received the information requested by the Commissioner; and
(2) Information requested is necessary for the Commissioner to render a final written decision on the complaint.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.20 - Certification of HMO Medical Directors › Section 31.10.20.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Administration" means the Maryland Insurance Administration.
(2) "Board" means the State Board of Physician Quality Assurance established under Health Occupations Article, Title 14, Annotated Code of Maryland.
(3) "Certificate" means a certificate, issued by the Commissioner under this chapter, to act as a medical director.
(4) "Commissioner" means the State Insurance Commissioner.
(5) "Contact information" means an individual's name, job title and department, address, telephone number, facsimile number, and email address.
(6) "Department" means the Department of Health and Mental Hygiene.
(7) "Governing authority" means the person or persons designated in the bylaws with the responsibility for operating the health maintenance organization.
(8) "Health maintenance organization" has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.
(9) Medical Director.
(a) "Medical director" means a physician employed by or under contract with a health maintenance organization who is responsible for:
(i) The establishment or maintenance of the policies and procedures at the health maintenance organization for quality assurance and utilization management;
(ii) Compliance with the quality assurance and utilization management policies and procedures of the health maintenance organization; and
(iii) Oversight of utilization review decisions of private review agents employed by or under contract with the health maintenance organization.
(b) "Medical director" includes an associate medical director or an assistant medical director who has been delegated any of the functions of a medical director.
(10) "Quality assurance" means a formal set of activities to review the quality of medical services provided to those persons covered by the health maintenance organization including implementation of corrective actions to address any deficiencies identified in the care and services provided to those persons covered by the health maintenance organization.
(11) "Utilization management" means the process of evaluating and determining the appropriateness of the utilization of covered medical services, including prior authorization, concurrent review, retrospective review, discharge planning, and case management.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.20 - Certification of HMO Medical Directors › Section 31.10.20.02 - Issuance of a Temporary Certificate

Current through Register Vol. 51, No. 14, July 12, 2024
A. Not later than the date of hire, a medical director seeking temporary certification shall submit to the Commissioner an application for certification on a form specified by the Commissioner.
B. The medical director shall attach the following additional information to the application:
(1) A description of the applicant's professional qualifications, including medical education, medical training and experience, clinical experience, history of malpractice claims, and licensures;
(2) Evidence of one of the following:
(a) An advanced health-related degree,
(b) Current board certification from either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA), or
(c) A minimum of 5 years clinical experience;
(3) Evidence of licensure status;
(4) Disclosure of any disciplinary action or sanction taken by any hospital, professional board, or regulating entity;
(5) The name, address, phone number, and facsimile number of the health maintenance organization, and the name of the governing authority of the health maintenance organization that the applicant is employed by or contracted with as a medical director; and
(6) The date of hire or expected date of hire.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.20 - Certification of HMO Medical Directors › Section 31.10.20.03 - Certification

Current through Register Vol. 51, No. 14, July 12, 2024
A. A medical director shall hold a certificate from the Commissioner that authorizes the applicant to act as the medical director of a health maintenance organization.
B. To qualify for a certificate to act as a medical director of a health maintenance organization, the applicant:
(1) Shall be a physician licensed to practice medicine in Maryland;
(2) Shall have one of the following:
(a) An advanced health-related degree,
(b) Current board certification from either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA), or
(c) A minimum of 5 years clinical experience;
(3) May not receive any direct or indirect financial compensation that:
(a) Violates Health-General Article, §19-705.1, Annotated Code of Maryland, or
(b) Deters the delivery of medically appropriate care to an enrollee; and
(4) Shall be of good character and trustworthy.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.20 - Certification of HMO Medical Directors › Section 31.10.20.04 - Denial or Revocation of Certification

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Commissioner shall deny a certificate to an applicant if the Commissioner finds that the initial application does not meet the requirements of this chapter.
B. The Commissioner may revoke the certification of a medical director:
(1) Who violates any provision of this chapter;
(2) Who fails to meet the requirements for certification under Regulation .04B of this chapter;
(3) Who obtains certification based on inaccurate information;
(4) Who fraudulently or deceptively obtains, attempts to obtain, or uses a certificate; or
(5) If the Commissioner finds a pattern that the utilization management procedures and policies used by the medical director in making utilization review decisions or used by a private review agent employed by or under contract with the health maintenance organization over whose utilization review decisions the medical director has responsibility are not:
(a) Objective,
(b) Clinically valid,
(c) Compatible with established principles of health care, or
(d) Flexible enough to allow deviations from the norms when justified on a case by case basis.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.20 - Certification of HMO Medical Directors › Section 31.10.20.05 - Term of Certification and Recertification

Current through Register Vol. 51, No. 14, July 12, 2024
A. A certificate:
(1) Is not transferable; and
(2) Expires on the second anniversary of its effective date unless certification has been renewed for another 2-year term.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.20 - Certification of HMO Medical Directors › Section 31.10.20.06 - Notification to the Board of Physician Quality Assurance

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Commissioner shall annually provide to the Board a list of certified individuals authorized by the Commissioner to act as a medical director.
B. The Commissioner shall notify the Board of the revocation of a certificate issued under this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.02 - Certification

Current through Register Vol. 51, No. 14, July 12, 2024
A. A private review agent shall hold a certificate from the Commissioner to conduct utilization review in this State.
B. A private review agent shall submit to the Commissioner the contact information of one person who will be available to respond to inquiries from the Maryland Insurance Administration. If the contact information for the designated person changes, the private review agent shall:
(1) Notify the Commissioner in writing within 30 days; and
(2) Provide new contact information.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.02-1 - Uniform Treatment Plan

Current through Register Vol. 51, No. 14, July 12, 2024
A. Scope. This regulation does not apply to a person that uses a treatment plan form solely for internal purposes, unless the private review agent requires the information to authorize treatment.
B. Form Required. If a private review agent requires a health care provider to submit a treatment plan or telephonically provide the information requested on the uniform treatment plan, to enable the private review agent to conduct utilization review of services for the treatment of a mental illness, emotional disorder, or a substance abuse disorder, the private review agent shall use the uniform treatment plan form set forth in §H of this regulation.
C. Acceptance of Form by Private Review Agent. A private review agent shall accept the uniform treatment plan form as a properly submitted treatment plan form and may not require a health care provider to:
(1) Modify the uniform treatment plan form or its content except as provided in this regulation; or
(2) Submit additional treatment plan forms.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.03 - Specific Criteria and Standards

Current through Register Vol. 51, No. 14, July 12, 2024
A. Required Copies. Upon the written request of a person or health care facility, a private review agent shall provide one copy of the specific criteria and standards to be used in conducting utilization review of proposed or delivered services and any subsequent revisions or modifications to the specific criteria and standards.
B. Fee for Copy. A private review agent shall:
(1) Make available a copy of specific criteria and standards used in conducting utilization review of proposed or delivered services for inspection on the premises during normal business hours;
(2) Provide a copy of the specific criteria and standards to a person or health care facility upon request at a reasonable fee determined by the private review agent; and
(3) Provide a copy of the specific criteria and standards upon request to a State agency at no charge to the agency.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.04 - Determinations

Current through Register Vol. 51, No. 14, July 12, 2024
A. Nonemergency Treatment. A private review agent shall make all initial determinations on whether to authorize or certify a nonemergency course of treatment for a patient within the time period specified in Insurance Article, § 15-10 B-06, Annotated Code of Maryland.
B. Extended Stays or Additional Health Care Services. A private review agent shall make all determinations on whether to authorize or certify an extended stay in a health care facility or additional health care services within the time period specified in Insurance Article, § 15-10 B-06, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.05 - Patient Referrals by Private Review Agents

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as provided in §B of this regulation, this regulation does not apply to:
(1) A private review agent referring an individual to a health care provider or facility that participates in a health maintenance organization;
(2) A preferred provider organization network of participating health care providers or facilities to which the individual would otherwise be referred as part of the individual's membership or insurance contract; or
(3) An employee assistance program referring an individual to a network of participating health care providers or facilities in accordance with a contract with the individual's employer or labor union to provide comprehensive mental health and substance abuse services.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.06 - Denial or Revocation of Certification

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Commissioner shall deny a certificate to an applicant if the Administration finds that the initial application does not include all requirements of Regulation .02 of this chapter.
B. The Commissioner may revoke the certification of a private review agent:
(1) That violates any provision of this chapter;
(2) That fraudulently or deceptively obtains, attempts to obtain, or uses a certificate;
(3) That fails to meet the requirements for certification under Regulation .02B of this chapter;
(4) That obtains certification based on inaccurate information; or
(5) If the Commissioner finds a pattern that the utilization management procedures and policies used by a private review agent are not:
(a) Objective,
(b) Clinically valid,
(c) Compatible with established principles of health care, or
(d) Flexible enough to allow deviations from the norms when justified on a case by case basis.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.07 - Term of Certification and Recertification

Current through Register Vol. 51, No. 14, July 12, 2024
A. A certificate of registration:
(1) Is not transferable; and
(2) Expires on the second anniversary of its effective date unless certification has been renewed for another 2-year term.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.08 - Penalties

Current through Register Vol. 51, No. 14, July 12, 2024
A. Criminal Penalty. A person who violates a provision of this chapter shall be guilty of a misdemeanor, and on conviction is subject to a penalty not exceeding $1,000. Each day a violation is continued after the first conviction is a separate offense.
B. Administrative Penalty. In addition to, or instead of, the criminal penalty described in §A of this regulation, the Commissioner may impose an administrative penalty not to exceed $5,000 for violation of any regulation of this chapter.
C. When considering whether conditions warrant the imposition of an administrative penalty, the Commissioner shall consider the following factors:
(1) The nature and seriousness of each condition of noncompliance;
(2) The number of conditions of noncompliance;
(3) The extent to which a condition of noncompliance is part of an ongoing pattern;
(4) The efforts made by, and the ability of the private review agent to correct, the condition of noncompliance in a timely manner; and
(5) Other factors as justice may require.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.09 - Hearings and Appeals

Current through Register Vol. 51, No. 14, July 12, 2024
A private review agent subject to an administrative penalty, or to denial or revocation of certification, has the right to a hearing and the right to appeal from an action of the Commissioner in accordance with Insurance Article, §§
									2-210 -2-215, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.10 - Exemptions

Current through Register Vol. 51, No. 14, July 12, 2024
The Commissioner may waive the requirements of this chapter for a private review agent that operates solely under contract with the federal government for utilization review of patients eligible for hospital services under Title XVIII of the Social Security Act.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.21 - Private Review Agents › Section 31.10.21.11 - Accredited Private Review Agents and Filing Requirement Waivers

Current through Register Vol. 51, No. 14, July 12, 2024
A. Determination of Approved Accrediting Organization.
(1) An accrediting organization is not an approved accrediting organization until the Commissioner issues a letter of approval to the accrediting organization.
(2) For the purpose of determining which entities are approved accrediting organizations, the Commissioner shall consider whether:
(a) Some or all of the accreditation standards required to be met for accreditation by the accrediting organization meet or exceed the requirements of Insurance Article, Title 15, Subtitles 10A and 10B, Annotated Code of Maryland;
(b) The accrediting organization measures an applicant's ability to meet each standard; and
(c) The accrediting organization agrees to notify the Commissioner at least 30 days in advance if it revises its accreditation standards or changes the method in which it reviews private review agents.
(3) The approved accrediting organization continues to be approved by the Commissioner until notified in writing by the Commissioner that its approval has been withdrawn.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
The scope of this chapter is the scope of Health-General Article, Title 19, Subtitle 7A, Annotated Code of Maryland, as it relates to the Insurance Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Commissioner" means the Maryland Insurance Commissioner.
(2) "Contract" means the contractual agreement for the provision of health care services on a prepaid, capitated basis entered into between a provider-sponsored organization and the Health Care Finance Administration to provide health care benefits to medicare program beneficiaries.
(3) "Enrollee" means an individual who is enrolled in a provider-sponsored organization.
(4) Health Care Delivery Assets.
(a) "Health care delivery assets" means any tangible asset that is part of a provider-sponsored organization operation.
(b) "Health care delivery assets" includes:
(i) Hospitals, medical facilities, and their ancillary equipment; and
(ii) Property as may reasonably be required for a provider-sponsored organization's principal office or for such purposes as may be necessary in the transaction of the business of a provider-sponsored organization.
(5) "Health Care Finance Administration" means the Health Care Finance Administration of the federal Department of Health and Human Services.
(6) "Health care services" means a health or medical procedure or service rendered by a health care provider that:
(a) Provides testing, diagnosis, or treatment of a human disease or dysfunction; or
(b) Dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction.
(7) "Insolvent" means the condition of having been:
(a) Declared as not meeting the fiscal requirements for continued licensing; or
(b) Placed under an order of liquidation by a court of competent jurisdiction.
(8) "Leasehold estate improvements" means improvements made to property that is leased by a provider-sponsored organization and used by it to provide health care services directly.
(9) "Net worth" means the excess of total admitted assets over liabilities, but the liabilities may not include fully subordinated debt.
(10) "Provider" means a physician, hospital, or other person licensed or otherwise authorized to provide health care services.
(11) "Provider-sponsored organization" has the meaning stated in Health-General Article, § 19-7 A-01(f), Annotated Code of Maryland.
(12) "Subordinated debt" means a surplus account item derived from the subordination of provider-sponsored organization debts to owners, medical providers, or other creditors.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.03 - Certificate of Authority Required

Current through Register Vol. 51, No. 14, July 12, 2024
Before a person may operate as a provider-sponsored organization under the federal Medicare+Choice Program, the person shall obtain a certificate of authority from the Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.04 - Application for Certificate of Authority

Current through Register Vol. 51, No. 14, July 12, 2024
A. Submission of Application. An applicant shall submit an application for a certificate of authority to the Commissioner at least 90 days before the date that the applicant proposes to engage in business in the State.
B. Provision of Application Form. The Commissioner shall provide an application form to an applicant on request.
C. Filing of Information. Each applicant seeking a certificate of authority to transact business in the State shall file the following items with the Commissioner:
(1) If incorporated, a copy of the articles of incorporation of the applicant and any amendments to the articles of incorporation, certified by the Department of Assessments and Taxation;
(2) A copy of the applicant's current bylaws, certified by the appropriate officer of the applicant;
(3) A list of the names, addresses, and official capacity with the applicant of the individuals who are to be responsible for conducting the applicant's affairs, including all members of the governing body, the officers and directors in the case of a corporation, and the partners or associates in the case of a partnership or association;
(4) A resume of the qualifications of the administrator, the medical director, each officer, and each other individual associated with the applicant or as requested by the Commissioner;
(5) A statement generally describing the:
(a) Applicant and its structure,
(b) Applicant's operations,
(c) The location of the facilities at which health care services will be regularly available to members, and
(d) The type, specialty, and number of physicians and health care personnel engaged or contracted with to provide health care services;
(6) A statement describing with reasonable certainty the geographic area to be served by the applicant;
(7) A certified statement of the financial condition of the applicant, including:
(a) Sources of financial support,
(b) Assets and liabilities and minimum net worth, and
(c) Other financial information the Commissioner requires for adequate financial evaluation;
(8) Copies of proposed techniques and methods of marketing the services of the applicant;
(9) A power of attorney duly executed by the applicant appointing the Commissioner and the Commissioner's duly authorized deputies as the true and lawful attorney of the applicant in and for the State on whom may be served all lawful process in any action, proceeding, or cause of action arising in the State against the applicant;
(10) A certificate of compliance evidencing employee coverage under the Maryland Workers' Compensation Act (Labor and Employment Article, Title 9, Annotated Code of Maryland); and
(11) A prospective budget and expected cash flow analysis for the first 12 months of the applicant's anticipated operation, demonstrating its financial viability based on reasonable assumptions.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.05 - Net Worth Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Initial Net Worth. An applicant may not obtain a certificate of authority unless the applicant has an initial net worth of at least:
(1) $1,500,000; or
(2) $1,000,000, based on evidence from the applicant's financial plan, as required by 42 CFR §
											422.384, demonstrating to the Commissioner's satisfaction that the applicant has available to it an administrative infrastructure that the Commissioner considers appropriate to reduce, control, or eliminate start-up administrative costs.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.06 - Determination of Financial Condition

Current through Register Vol. 51, No. 14, July 12, 2024
A. Additional Assets. In any determination of the financial condition of an applicant or provider-sponsored organization, in addition to the assets under Regulation .05 of this chapter, the following assets are allowed:
(1) Cash in the possession of the applicant or provider-sponsored organization or in transit under its control, and the balance of any deposit of the applicant or provider-sponsored organization in a solvent bank or trust company;
(2) Investments and securities owned and held by the applicant or provider-sponsored organization, free and clear of any liens, encumbrances, pledges, or judgements, and the income due or accrued on the investments and securities;
(3) Member premium charges in the course of collection, not more than 90 days past due (the foregoing limitation does not apply to amounts payable directly by the federal government under the Medicare+Choice contract);
(4) Health care delivery assets in accordance with Regulation .05C of this chapter;
(5) Prepaid charges on contracts with other organizations or hospitals, or other persons as approved by the Commissioner;
(6) Pharmaceutical and medical supply inventories;
(7) Cost of land and depreciated cost of buildings owned and occupied by the applicant or provider-sponsored organization and used to directly provide health care, in excess of any encumbrances on it;
(8) Leasehold estate improvements, if the initial cost is amortized over the useful life of the improvements but not beyond the termination of the lease;
(9) Electronic, mechanical, and computer hardware including the operating system software used for data processing and accounting purposes, the cost of which shall be amortized in full over a period not to exceed 5 calendar years; and
(10) Other assets, not inconsistent with the foregoing provisions, deemed by the Commissioner available for the provision of health care, at values to be determined by the Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.07 - Deposit of Securities

Current through Register Vol. 51, No. 14, July 12, 2024
A. Deposit Required. The Commissioner may not issue or renew a certificate of authority for a provider-sponsored organization unless it has deposited and maintains in trust with the State Treasurer, for the protection of its members or its members and creditors, cash or government securities of the type described in Health-General Article, §19-710, Annotated Code of Maryland, in the market value amount of $100,000.
B. Assets.
(1) For purposes of determining net worth, the deposit is an admitted asset of the provider-sponsored organization.
(2) All income from deposits is an asset of the provider-sponsored organization.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.08 - Term and Renewal of Certificate of Authority

Current through Register Vol. 51, No. 14, July 12, 2024
A. Expiration. Unless previously suspended or revoked, each original and renewal certificate of authority issued to a provider-sponsored organization expires at midnight on the November 30 after its effective date in accordance with Health-General Article, §19-721(a), Annotated Code of Maryland.
B. Renewal. On payment of an annual renewal fee of $25 by the provider-sponsored organization before the expiration date of its certificate of authority, its certificate of authority remains in effect until a new certificate of authority is issued or specifically refused in accordance with Health-General Article, §19-721, Annotated Code of Maryland.
C. Refusal to Renew. The Commissioner may refuse to renew a certificate of authority in accordance with Health-General Article, §19-722, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.09 - Disciplinary Action

Current through Register Vol. 51, No. 14, July 12, 2024
If a provider-sponsored organization violates any provision of Health-General Article, §19-729, Annotated Code of Maryland, the Commissioner may take any action against the provider-sponsored organization that is authorized pursuant to Health-General Article, §19-730, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.10 - Change of Name

Current through Register Vol. 51, No. 14, July 12, 2024
A provider-sponsored organization may not:
A. Use a name that has not been approved by the Commissioner; or
B. Change its name without the prior approval of the Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.11 - Termination of Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. Notice of Intent to Terminate. When a provider-sponsored organization desires to cease offering a service under the contract, the provider-sponsored organization shall provide written notice of the intent to terminate to the Commissioner at least 30 days before ceasing to offer the service.
B. Permissible Reasons for Cancellation or Nonrenewal of Enrollment. A provider-sponsored organization may cancel or nonrenew enrollment in the provider-sponsored organization only for the following reasons:
(1) Change of the place of residence of the member from the geographical area served by the provider-sponsored organization;
(2) Failure of the member to pay any deductible or co-payment charges permitted under a contract;
(3) Fraudulent use of the provider-sponsored organization's identification card on the part of the member or the alteration or sale of prescriptions by the member;
(4) Failure of the enrollee to pay a premium charge when due;
(5) Termination of the contract.
(6) Termination of the plan with respect to all individuals in the area in which the enrollee resides; or
(7) The enrollee has:
(a) Engaged in disruptive behavior as specified in standards under 42 U.S.C. §
												1395w-21,
(b) Lost entitlement to Part A or Part B of Title 42, Chapter 7, Subchapter XVIII of the U.S. Code, or
(c) Died.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.12 - Annual Report

Current through Register Vol. 51, No. 14, July 12, 2024
A. Required. Each licensed provider-sponsored organization shall file with the Commissioner a report, certified by at least two principal officers, showing its financial condition on the last day of the preceding calendar year.
B. Form. The report shall be on the form adopted by the Commissioner.
C. Filing Deadline. Unless the time is extended for good cause, a provider-sponsored organization shall file its annual report with the Commissioner on or before the first day of March of each year.
D. Supplemental Information. The report shall be supplemented with a description of any changes in the information submitted with the last previous annual report or with the provider-sponsored organization's original application for a certificate of authority.
E. Audited Financial Statement. A provider-sponsored organization shall file a certified audited financial statement on or before June 1 of each year.
F. Additional Reports. The Commissioner may require additional reports as are deemed necessary and appropriate to enable the Commissioner to carry out the duties of the Commissioner under the law.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.13 - Fiscal Examination

Current through Register Vol. 51, No. 14, July 12, 2024
A. Frequency of Examination. The Commissioner may examine the operation of a provider-sponsored organization as often as the Commissioner deems necessary for the protection of the interest of the people of Maryland, but the examinations may not be less frequent than once every 5 years.
B. Cost of Examination.
(1) The Commissioner shall assess the provider-sponsored organization being examined for the cost of the examination.
(2) The provider-sponsored organization shall remit the cost of the examination to the Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.14 - General Operations of a Provider-Sponsored Organization

Current through Register Vol. 51, No. 14, July 12, 2024
A. Effective Date of Contract. A provider-sponsored organization shall inform the Commissioner of the effective date of its contract.
B. Review of Agreements by Commissioner. All signed written agreements, including those defining physicians' services, shall be on file and available for review by the Commissioner at all times in the provider-sponsored organization's central office.
C. Duration of Agreements. All agreements shall have a duration of 12 months.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.22 - Provider - Sponsored Organizations › Section 31.10.22.15 - Insurance - Catastrophic or Back-Up Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
A. Insurance Coverage Required. Unless the Commissioner grants an exemption from the requirements of this section, a provider-sponsored organization shall secure insurance coverage to provide:
(1) Payments or services required to be made or furnished under the health care contract to those enrollees who are injured or become ill outside the geographic limits served by the provider-sponsored organization; and
(2) Reinsurance protection to the provider-sponsored organization in the event of catastrophic or unusual losses that would be in excess of the levels of loss that the provider-sponsored organization assumes in the basis of its calculation of premium charges.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.23 - Penalties for Failure to Make Prompt Payment of Claims › Section 31.10.23.01 - Violations Subject to Penalties

Current through Register Vol. 51, No. 14, July 12, 2024
A. Violations. In addition to the requirement that an insurer, nonprofit health service plan, or health maintenance organization pay interest as required under Insurance Article, §
									15-1005(f), Annotated Code of Maryland, an insurer, nonprofit health service plan, or health maintenance organization is subject to the penalties set forth in §B of this regulation if the insurer, nonprofit health service plan, or health maintenance organization:
(1) Fails to:
(a) Pay a claim within 30 days after receipt of a claim for reimbursement from a:
(i) Person entitled to reimbursement under Insurance Article, §
												15-701(a), Annotated Code of Maryland, or
(ii) Hospital or related institution as defined in Health-General Article, §19-301, Annotated Code of Maryland; or
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.24 - Discount Medical Plan Organizations and Discount Drug Plan Organizations › Section 31.10.24.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to discount medical plans and discount drug plans sold, marketed, or solicited in Maryland in accordance with the requirements of Insurance Article, Title 14, Subtitle 6, Annotated Code of Maryland.