2013 Maryland Code
HEALTH - GENERAL
§ 19-705 - Rules and regulations

§19-705.

(a) (1) The Secretary may adopt rules, regulations, and standards for the quality of health care services provided by a health maintenance organization through its benefit packages.

(2) With the advice of the Department, the Commissioner shall adopt reasonable rules and regulations as necessary to carry out any other provisions of this subtitle.

(b) (1) The Commissioner and the Department shall adopt joint internal procedures to help them work together to carry out their duties under this subtitle.

(2) The joint internal procedures shall establish means by which the Commissioner and the Department may inform each other promptly on matters that affect any health maintenance organization, including:

(i) Any important action, change, or rearrangement that a health maintenance organization may undertake; and

(ii) Any regulatory problem.

§ 19-705 - 1. Standards of quality of care

(a) Adoption of regulations. -- The Secretary shall adopt regulations that set out reasonable standards of quality of care that a health maintenance organization shall provide to its members.

(b) Contents of standards. --

(1) The standards of quality of care shall include:

(i) 1. A requirement that a health maintenance organization shall provide for regular hours during which a member may receive services, including providing for services to a member in a timely manner that takes into account the immediacy of need for services; and

2. Provisions for assuring that all covered services, including any services for which the health maintenance organization has contracted, are accessible to the enrollee with reasonable safeguards with respect to geographic locations;

(ii) A requirement that a health maintenance organization shall have a system for providing a member with 24-hour access to a physician in cases where there is an immediate need for medical services, and for promoting timely access to and continuity of health care services for members, including:

1. Providing 24-hour access by telephone to a person who is able to appropriately respond to calls from members and providers concerning after-hours care; and

2. Providing a 24-hour toll free telephone access system for use in hospital emergency departments in accordance with § 19-705.7 of this subtitle;

(iii) A requirement that any nonparticipating provider shall submit to the health maintenance organization the appropriate documentation of the medical complaint of the member and the services rendered;

(iv) A requirement that a health maintenance organization shall have a physician available at all times to provide diagnostic and treatment services;

(v) A requirement that a health maintenance organization shall assure that:

1. Each member who is seen for a medical complaint is evaluated under the direction of a physician; and

2. Each member who receives diagnostic evaluation or treatment is under the medical management of a health maintenance organization physician who provides continuing medical management;

(vi) A requirement that each member shall have an opportunity to select a primary physician or a certified nurse practitioner from among those available to the health maintenance organization; and

(vii) A requirement that a health maintenance organization print, in any directory of participating providers or hospitals, in a conspicuous manner, the address, telephone number, and facsimile number of the State agency that members, enrollees, and insureds may call to discuss quality of care issues, life and health insurance complaints, and assistance in resolving billing and payment disputes with the health plan or health care provider, as follows:

1. For quality of care issues and life and health care insurance complaints, the Maryland Insurance Administration; and

2. For assistance in resolving a billing or payment dispute with the health plan or a health care provider, the Health Education and Advocacy Unit of the Consumer Protection Division of the Office of the Attorney General.

(2) This subsection may not be construed to require that a health maintenance organization include certified nurse practitioners on the health maintenance organization's provider panel as primary care providers.

(c) Certified nurse practitioner as primary care provider. --

(1) The health maintenance organization shall make available and encourage appropriate history and baseline examinations for each member within a reasonable time of enrollment set by it.

(2) Medical problems that are a potential hazard to the person's health shall be identified and a course of action to alleviate these problems outlined.

(3) Progress notes indicating success or failure of the course of action shall be recorded.

(4) The health maintenance organization shall:

(i) Offer or arrange for preventive services that include health education and counseling, early disease detection, immunization, and hearing loss screening of newborns provided by a hospital before discharge;

(ii) Develop or arrange for periodic health education on subjects which impact on the health status of a member population; and

(iii) Notify every member in writing of the availability of these and other preventive services.

(5) The health maintenance organization shall offer services to prevent a disease if:

(i) The disease produces death or disability and exists in the member population;

(ii) The etiology of the disease is known or the disease can be detected at an early stage; and

(iii) Any elimination of factors leading to the disease or immunization has been proven to prevent its occurrence, or early disease detection followed by behavior modification, environmental modification, or medical intervention has been proven to prevent death or disability.

(d) Written plan. --

(1) To implement these standards of quality of care, a health maintenance organization shall have a written plan that is updated and reviewed at least every 3 years.

(2) The plan shall include the following information:

(i) Statistics on age, sex, and other general demographic data used to determine the health care needs of its population;

(ii) Identification of the major health problems in the member population;

(iii) Identification of any special groups of members that have unique health problems, such as the poor, the elderly, the mentally ill, and educationally disadvantaged; and

(iv) A description of community health resources and how they will be used.

(3) The health maintenance organization shall state its priorities and objectives in writing, describing how the priorities and objectives relating to the health problems and needs of the member population will be provided for.

(4) (i) The health maintenance organization shall provide at the time membership is solicited a general description of the benefits and services available to its members, including benefit limitations and exclusions, location of facilities or providers, and procedures to obtain medical services.

(ii) The health maintenance organization shall place the following statement, in bold print, on every enrollment card or application: "If you have any questions concerning the benefits and services that are provided by or excluded under this agreement, please contact a membership services representative before signing this application or card".

(5) The plan shall contain evidence that:

(i) The programs and services offered are based on the health problems of and the community health services available to its member population;

(ii) There is an active program for preventing illness, disability, and hospitalization among its members; and

(iii) The services designed to prevent the major health problems identified among child and adult members and to improve their general health are provided by the health maintenance organization.

(e) Internal peer review system. --

(1) The health maintenance organization shall have an internal peer review system that will evaluate the utilizational services and the quality of health care provided to its members.

(2) The review system shall:

(i) Provide for review by appropriate health professionals of the process followed in the provision of health services;

(ii) Use systematic data collection of performances and patient results;

(iii) Provide interpretation of this data to the practitioners;

(iv) Review and update continuing education programs for health professionals providing services to its members;

(v) Identify needed change and proposed modifications to implement the change; and

(vi) Maintain written records of the internal peer review process.

(f) External review of quality. --

(1) Except as provided in paragraph (5) of this subsection, the Department shall conduct an annual external review of the quality of the health services of the health maintenance organization in a manner that the Department considers to be appropriate.

(2) The external review shall be conducted by:

(i) A panel of physicians and other health professionals that consists of persons who:

1. Have been approved by the Department;

2. Have substantial experience in the delivery of health care in a health maintenance organization setting, but who are not members of the health maintenance organization staff or performing professional services for the health maintenance organization; and

3. Reside outside the area serviced by the health maintenance organization;

(ii) The Department; or

(iii) A federally approved professional standards review organization.

(3) The final decision on the type of external review that is to be employed rests solely with the Secretary.

(4) The external review shall consist of a review and evaluation of:

(i) An internal peer review system and reports;

(ii) The program plan of the health maintenance organization to determine if it is adequate and being followed;

(iii) The professional standards and practices of the health maintenance organization in every area of services provided;

(iv) The grievances relating specifically to the delivery of medical care, including their final disposition;

(v) The physical facilities and equipment; and

(vi) A statistically representative sample of member records.

§ 19-705 - 2. Complaints of members and subscribers

(a) Complaint system -- Establishment. -- With the advice of the Secretary, the Commissioner shall adopt regulations to establish a system for the receipt and timely investigation of complaints of members and subscribers of health maintenance organizations concerning the operation of any health maintenance organization in this State.

(b) Complaint system -- Contents and included procedures. -- The complaint system shall include:

(1) A procedure for the timely acknowledgment of receipt of a complaint;

(2) Criteria that the Secretary shall adopt by regulation for determining the appropriate level of investigation for a complaint concerning quality of care, including:

(i) A determination as to whether the member or subscriber with the complaint previously attempted to have the complaint resolved; and

(ii) A determination as to whether a complaint should be sent to the member's or subscriber's health maintenance organization for resolution prior to investigation under the provisions of this section; and

(3) A procedure for the referral of quality of care complaints to the Secretary for an appropriate investigation.

(c) Investigations. -- If a determination is made to investigate a complaint under the provisions of this section prior to the member or subscriber attempting to otherwise resolve the complaint, the reasons for that determination shall be documented.

(d) Notice of establishment of system. -- Notice of the complaint system established under the provisions of this section shall be included in all contracts between a health maintenance organization and a member or subscriber of a health maintenance organization.

(e) Reports on investigations. -- For quality of care complaints referred to the Secretary for investigation under subsection (b) (3) of this section, the Secretary shall report to the Commissioner in a timely manner on the results and findings of each investigation.

§ 19-705 - 3. Centers for Disease Control and Prevention's guidelines on universal precautions

(a) "Health maintenance organization" defined. -- In this section, "health maintenance organization" means a health maintenance organization where health care services are delivered by health care providers to subscribers at a central facility or centralized system of facilities operated by the health maintenance organization.

(b) Regulations for compliance and display of notice. -- The Department shall adopt regulations to require health maintenance organizations to:

(1) Adopt, implement, and enforce a policy that requires, except in an emergency life-threatening situation where it is not feasible or practicable, all employees and medical staff involved in patient care services to comply with the Centers for Disease Control and Prevention's guidelines on universal precautions; and

(2) Display the notice developed under § 1-207 of the Health Occupations Article at the entrance to the health maintenance organization.

(c) Penalties. -- If the health maintenance organization fails to comply with the requirements of this section the Secretary may impose a penalty of up to $ 500 per day per violation for each day a violation continues.

§ 19-705 - 4. Limitations on covered services and visits

(a) Limitations on covered services. -- Any limitation imposed by a health maintenance organization on the receipt of covered services provided to a member or subscriber by a physical therapist licensed under Title 13 of the Health Occupations Article may only be imposed per incident or per injury within a contract period.

(b) Limitations on number of visits. -- This subsection may not be construed to prohibit a health maintenance organization from imposing any limitations on the number of visits permitted for a member or subscriber.

§ 19-705 - 5. Coverage for inherited metabolic disease

(a) Definitions. --

(1) In this section the following words have the meanings indicated.

(2) (i) "Inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry.

(ii) "Inherited metabolic disease" includes a disease for which the State screens newborn babies.

(3) (i) "Low protein modified food product" means a food product that is:

1. Specially formulated to have less than 1 gram of protein per serving; and

2. Intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease.

(ii) "Low protein modified food product" does not include a natural food that is naturally low in protein.

(4) "Medical food" means a food that is:

(i) Intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation; and

(ii) Formulated to be consumed or administered enterally under the direction of a physician.

(b) Treatment. -- A health maintenance organization shall include as part of its benefit package of health care services to be provided to members and subscribers coverage for medical foods and low protein modified food products for the treatment of inherited metabolic diseases if the medical foods and low protein modified food products are:

(1) Prescribed as medically necessary for the therapeutic treatment of inherited metabolic diseases; and

(2) Administered under the direction of a physician.

§ 19-705 - 6. Emergency services

(a) Physician on call. -- If it is necessary to provide emergency services, authorization shall be presumed for utilizing the medical or surgical provider on call for unassigned patients or the appropriate specialist on call for the hospital on that date if:

(1) A telephone access system is not operational at the time of the call; or

(2) A member's primary care provider or the specialist needed by a member cannot be determined within a reasonable time, as determined by the treating emergency physician but not to exceed 30 minutes after the initial documented call to the telephone access system.

(b) Service area. -- This section may not be construed to require a health maintenance organization to have contracted specialist providers at hospitals outside of the service area of the health maintenance organization.

§ 19-705 - 7. Toll-free telephone access

The 24-hour toll free telephone access system provided by each health maintenance organization shall:

(1) Enable members and providers to determine, with one telephone call, the primary care provider assigned to a member; and

(2) Enable providers to determine, with one telephone call, the names of three contracted specialist providers for the health maintenance organization who also have staff privileges at a particular hospital in the State.

§ 19-705 - 8. Health Maintenance Organization Quality Assurance Unit

(a) Definitions. --

(1) In this section the following words have the meanings indicated.

(2) "HMO Quality Assurance Unit" means the Health Maintenance Organization (HMO) Quality Assurance Unit in the Department.

(3) "Quality Assurance Medical Director" means the Medical Director of the HMO Quality Assurance Unit.

(b) Established. -- There is a Health Maintenance Organization (HMO) Quality Assurance Unit in the Department.

(c) Quality Assurance Medical Director. --

(1) The Secretary shall appoint the Quality Assurance Medical Director.

(2) The Quality Assurance Medical Director shall:

(i) Be a physician who is licensed in the State;

(ii) Be board certified in at least one specialty;

(iii) Have experience in primary care and administrative medicine; and

(iv) Have broad knowledge of health maintenance organizations and managed care organizations.

(3) The Quality Assurance Medical Director is entitled to the compensation provided in the State budget.

(4) Subject to the authority vested in the Secretary by law, the Quality Assurance Medical Director is in charge of and responsible for the clinical operations of the HMO Quality Assurance Unit.

(5) In accordance with the State budget the Secretary may employ staff for the HMO Quality Assurance Unit.

(d) Duties of Unit. -- The HMO Quality Assurance Unit shall:

(1) Enforce all requirements established under §§ 19-705 and 19-705.1 of this subtitle and the regulations adopted under these provisions regarding the quality of health care provided by a health maintenance organization; and

(2) Investigate quality of care complaints referred to the Secretary under § 19-705.2(b)(3) of this subtitle.

(e) Duties of Medical Director. -- The Quality Assurance Medical Director shall:

(1) Determine whether a health maintenance organization meets the requirements established under §§ 19-705 and 19-705.1 of this subtitle and the regulations adopted under these provisions regarding the quality of health care provided by a health maintenance organization; and

(2) Make recommendations to the Secretary for corrective action necessary to meet these requirements.

(f) Secretary authorized to issue orders. -- If the Secretary agrees with a determination made by the Quality Assurance Medical Director that a health maintenance organization does not meet the requirements established under §§ 19-705 and 19-705.1 of this subtitle or the regulations adopted under these provisions regarding the quality of health care provided by a health maintenance organization, the Secretary may issue an order under § 19-731 of this subtitle.