§ 19-710. Certificate qualifications
West's Annotated Code of MarylandHealth--GeneralEffective: July 1, 2022 to June 30, 2025
Effective: July 1, 2022 to June 30, 2025
MD Code, Health - General, § 19-710
§ 19-710. Certificate qualifications
<Section effective until July 1, 2025. See, also, section 19-710 effective July 1, 2025.>
(a) To qualify for a certificate of authority to operate as a health maintenance organization, an applicant shall satisfy the Commissioner that the applicant will meet the requirements of this section.
(b) The applicant shall conform to the definition of a health maintenance organization.
(c) The applicant shall establish and operate a bona fide health maintenance organization that can provide health care services in the proposed geographic area.
(d)(1) The health maintenance organization shall be actuarially sound.
(iii) All health maintenance organizations shall maintain a surplus that exceeds the liabilities of the health maintenance organization in the amount that is at least equal to the greater of $750,000 or 5 percent of the subscription charges earned during the prior calendar year as recorded in the annual report filed by the health maintenance organization with the Commissioner.
2. For the purpose of applying this subparagraph, a health maintenance organization shall be treated as an insurer.
(e) The provisions of Title 4, Subtitle 3 (Risk Based Capital Standards for Insurers) and § 15-604 (Rates for Payments to Hospitals) of the Insurance Article apply to health maintenance organizations in the same manner as they apply to insurers.
(f) The terms of contracts, including any medical assistance program contracts under Title XVIII or Title XIX of the Social Security Act1 or Title III of the Public Health Service Act,2 proposed to be made or made with government or private agencies that cover all or part of the cost of subscriptions to provide health care services, facilities, appliances, medicines, or supplies shall be financially sound, based on reasonable actuarial assumptions that the health maintenance organization can meet its obligations to the agencies and their beneficiaries by reason of the health maintenance organization's net worth position, stop loss, reinsurance arrangements with authorized insurers, or other arrangements that are satisfactory to the Commissioner.
(g)(1) The terms of the contracts to be offered to subscribers shall provide that the health care services provided to members of the health maintenance organization will meet reasonable standards of quality of care that are applicable to the geographic area to be served, as approved by the Department.
(2) If a health maintenance organization offers services that are within the scope of practice of a physician and another health care practitioner who is licensed under the Health Occupations Article, the health maintenance organization shall offer those services through other licensed health care practitioners, where appropriate, as determined by the health maintenance organization.
(h) The procedures for offering health care services and offering and terminating contracts to subscribers may not discriminate unfairly on the basis of age, sex, race, health, or economic status. This requirement does not prohibit:
(i)(1) The terms of the agreements between a health maintenance organization and providers of health services shall contain a “hold harmless” clause.
(2) The hold harmless clause shall provide that the provider may not, under any circumstances, including nonpayment of money due the providers by the health maintenance organization, insolvency of the health maintenance organization, or breach of the provider contract, bill, charge, collect a deposit, seek compensation, remuneration, or reimbursement from, or have any recourse against the subscriber, member, enrollee, patient, or any persons other than the health maintenance organization acting on their behalf, for services provided in accordance with the provider contract.
(j) The health maintenance organization shall provide evidence of adequate insurance coverage or an adequate plan for self-insurance to satisfy claims for injuries that may occur from providing health care.
(k) The health maintenance organization shall provide for having its health and medical facilities and services audited and reviewed periodically:
(3) By a professional standards review organization, as described in Title XI of the Social Security Act, that is certified by the Department of Health and Human Services as capable of serving individuals in the area where the health maintenance organization operates who are receiving benefits under Title XVIII or Title XIX of the Social Security Act or Title III of the Public Health Service Act, if the professional standards review organization is acting consistently with its certification.
(l)(1) With the approval of the Department, the health maintenance organization shall provide continuous internal peer review for monitoring and evaluating patient records for:
(m) The health maintenance organization shall provide an internal grievance system to resolve adequately any grievances initiated by any of its members, in a manner approved by the Department on matters concerning quality of care and by the Commissioner on all other matters covered by this subtitle, under rules and regulations adopted under this subtitle.
(n) The health maintenance organization shall establish procedures to offer each member an opportunity to participate in matters of policy and operation.
(o) The health maintenance organization shall maintain a health and medical records system that:
1. The services provided;
2. When the services are provided;
3. Where the services are provided;
4. By whom the services are provided;
5. The diagnosis and prognosis, if appropriate;
6. The treatment;
7. Any drug therapy; and
8. The health status of the patient, if appropriate.
(p)(1) Except as provided in paragraph (3) of this subsection, individual enrollees and subscribers of health maintenance organizations issued certificates of authority to operate in this State may not be liable to any health care provider for any covered services provided to the enrollee or subscriber.
(ii) A health care provider or any representative of a health care provider may not maintain any action against any subscriber or enrollee to collect or attempt to collect any money owed to the health care provider by a health maintenance organization issued a certificate of authority to operate in this State.
(ii) If Medicare is the primary insurer and a health maintenance organization is the secondary insurer, any amount up to the Medicare approved or limiting amount, as specified under the Social Security Act, that is not owed to the health care provider by Medicare or the health maintenance organization after coordination of benefits has been completed, for Medicare covered services provided to the subscriber or enrollee by the health care provider; or
(q)(1) The Commissioner shall require each health maintenance organization to have an insolvency plan by January 1, 1990 which provides for:
1. The subscriber or enrollee is discharged from the inpatient health care facility; or
2. 365 days.
1. For the duration of the contract period for which premiums have been made; and
2. If admitted to an inpatient health care facility, until the enrollee or subscriber is discharged or 365 days, whichever occurs first;
(s)(1) In this subsection, “practice profile” means a profile, summary, economic analysis, or other analysis of data concerning services rendered or utilized by a provider under contract with or employed by a health maintenance organization for the provision of health care services by the provider to enrollees or subscribers of the health maintenance organization.
(2) If a health maintenance organization uses a practice profile as a factor in its contract review to evaluate a provider's status on a provider panel, the health maintenance organization shall disclose at the commencement and renewal of the contract and, not more often than annually, upon the request of the provider:
(4) A health maintenance organization may not terminate a provider contract or provider's employment with the health maintenance organization on the basis of a practice profile without first informing the provider of the findings of the practice profile and the provider specific data underlying those findings.
(t) A health maintenance organization may not by contract, or in any other manner, require a provider to indemnify the health maintenance organization or hold the health maintenance organization harmless from a coverage decision or negligent act of the health maintenance organization.
Credits
Added by Acts 1982, c. 21, § 2, eff. July 1, 1982. Amended by Acts 1984, c. 555, § 1, eff. July 1, 1984; Acts 1986, c. 816, § 1, eff. July 1, 1986; Acts 1988, c. 395, § 1, eff. July 1, 1988; Acts 1988, c. 703, § 2, eff. Nov. 1, 1988; Acts 1988, c. 754, § 2, eff. July 1, 1988; Acts 1989, c. 364, § 1, eff. July 1, 1989; Acts 1989, c. 610, § 1, eff. July 1, 1989; Acts 1991, c. 121, § 1, eff. July 1, 1991; Acts 1993, c. 635, § 2, eff. Oct. 1, 1993; Acts 1996, c. 503, § 1, eff. July 1, 1996; Acts 1996, c. 548, § 1, eff. Oct. 1, 1996; Acts 1997, c. 70, § 4, eff. Oct. 1, 1997; Acts 2000, c. 275, § 1, eff. Oct. 1, 2000; Acts 2000, c. 331, §§ 1, 2, eff. July 1, 2000; Acts 2003, c. 440, § 2, eff. Oct. 1, 2003; Acts 2004, c. 278, § 1, eff. Oct. 1, 2004; Acts 2014, c. 263, § 1, eff. July 1, 2014; Acts 2022, c. 271, § 1, eff. July 1, 2022; Acts 2022, c. 272, § 1, eff. July 1, 2022.
Formerly Art. 43, § 844.
Footnotes
Aug. 14, 1935, ch. 531, 49 Stat. 620, codified at 42 U.S.C.A. § 301 et seq.
July 1, 1944, ch. 373, 58 Stat. 682, codified at 42 U.S.C.A. § 201 et seq.
MD Code, Health - General, § 19-710, MD HEALTH GEN § 19-710
Current through legislation effective through April 25, 2024, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
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