§ 15-140. Continuity of health care during transitions from one carrier to another
West's Annotated Code of MarylandInsuranceEffective: January 1, 2015
Effective: January 1, 2015
MD Code, Insurance, § 15-140
§ 15-140. Continuity of health care during transitions from one carrier to another
(iv) “Health benefit plan” does not include the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether the benefits are provided under any group health plan maintained by the same plan sponsor:
1. a health care practitioner or group of health care practitioners licensed, certified, or otherwise authorized to provide, in the ordinary course of business or practice of a profession, health care services covered in a health benefit plan, the Maryland Medical Assistance Program, or the Maryland Children's Health Program; or
(b)(1) The purpose of this section is to advance the State's progress in:
(c)(1) With respect to any benefit or service provided through the Maryland Medical Assistance fee-for-service program, this subsection shall apply:
(2) Subject to paragraph (3) of this subsection, at the request of an enrollee or an enrollee's parent, guardian, designee, or health care provider, a receiving carrier or managed care organization shall accept a preauthorization from a relinquishing carrier, managed care organization, or third-party administrator for:
(3) Subject to applicable laws relating to the confidentiality of medical records, including 42 C.F.R. Part 2, at the request and with the consent of an enrollee or an enrollee's parent, guardian, or designee, a relinquishing carrier, managed care organization, or third-party administrator, shall provide a copy of a preauthorization to the enrollee's receiving carrier or managed care organization within 10 days after receipt of the request.
New enrollees allowed to continue to receive health care services by nonparticipating provider during transition
(d)(1) Subject to paragraphs (2) through (5) of this subsection, at the request of an enrollee or an enrollee's parent, guardian, designee, or health care provider, a receiving carrier or managed care organization shall allow a new enrollee to continue to receive health care services being rendered by a nonparticipating provider at the time of the enrollee's transition to the receiving health benefit plan or managed care organization.
(ii) Subject to paragraphs (4) and (5) of this subsection, the receiving carrier or managed care organization, with respect to the provision of the covered services, shall pay the nonparticipating provider the rate and method of payment the receiving carrier or managed care organization normally would pay and use for participating providers who provide similar services in the same or similar geographic area.
(iv) Subject to paragraphs (4) and (5) of this subsection, if the nonparticipating provider does not accept the rate or method of payment under subparagraph (ii) of this paragraph, the nonparticipating provider and the receiving carrier or managed care organization may reach agreement on an alternative rate or method of payment for the provision of covered services.
2. the copayments, deductibles, and any coinsurance required of an enrollee for the services rendered in accordance with this section are the same as those that would be required if the enrollee were receiving the services from a participating provider of the receiving carrier or managed care organization.
(5) If the nonparticipating provider does not accept the rate and method of compensation under paragraph (3)(ii) of this subsection, and the carrier or managed care organization does not reach an agreement with the nonparticipating provider for an alternative rate and method of payment under paragraph (3)(iv) of this subsection:
(e)(1) This section does not:
(2)(i) To ensure continuity of treatment in progress for dental services provided to an enrollee, a relinquishing carrier may elect to allow an enrollee to continue to receive dental services being provided by a participating provider of the relinquishing carrier through an arrangement in which the relinquishing carrier pays the participating provider according to the rate and method of payment the relinquishing carrier normally would pay and use for the participating provider.
(f)(1) A receiving carrier or managed care organization shall provide notice to a new enrollee of the enrollee's options and responsibilities under this section in a manner prescribed by the Commissioner.
(g) The Commissioner and the Secretary of Health each may adopt regulations to enforce the requirements of this section.
(h)(1) The Commissioner, the Maryland Health Benefit Exchange, and the Secretary of Health shall collaborate to determine the data, to the extent its collection is feasible and permitted by law, that is necessary to:
Credits
Added by Acts 2013, c. 159, § 3, eff. Jan. 1, 2015. Amended by Acts 2014, c. 45, § 1, eff. April 8, 2014; Acts 2017, c. 62, § 6.
MD Code, Insurance, § 15-140, MD INSURANCE § 15-140
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
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