Maryland Insurance Section 15-112

Article - Insurance

§ 15-112.

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

            (2)      (i)      "Carrier" means:

                        1.      an insurer;

                        2.      a nonprofit health service plan;

                        3.      a health maintenance organization;

                        4.      a dental plan organization; or

                        5.      any other person that provides health benefit plans subject to regulation by the State.

                  (ii)      "Carrier" includes an entity that arranges a provider panel for a carrier.

            (3)      "Enrollee" means a person entitled to health care benefits from a carrier.

            (4)      "Provider" means a health care practitioner or group of health care practitioners licensed, certified, or otherwise authorized by law to provide health care services.

            (5)      (i)      "Provider panel" means the providers that contract either directly or through a subcontracting entity with a carrier to provide health care services to the carrier's enrollees under the carrier's health benefit plan.

                  (ii)      "Provider panel" does not include an arrangement in which any provider may participate solely by contracting with the carrier to provide health care services at a discounted fee-for-service rate.

      (b)      A carrier that uses a provider panel shall establish procedures to:

            (1)      review applications for participation on the carrier's provider panel in accordance with this section;

            (2)      notify an enrollee of:

                  (i)      the termination from the carrier's provider panel of the primary care provider that was furnishing health care services to the enrollee; and

                  (ii)      the right of the enrollee, on request, to continue to receive health care services from the enrollee's primary care provider for up to 90 days after the date of the notice of termination of the enrollee's primary care provider from the carrier's provider panel, if the termination was for reasons unrelated to fraud, patient abuse, incompetency, or loss of licensure status;

            (3)      notify primary care providers on the carrier's provider panel of the termination of a specialty referral services provider; and

            (4)      notify a provider at least 90 days before the date of the termination of the provider from the carrier's provider panel, if the termination is for reasons unrelated to fraud, patient abuse, incompetency, or loss of licensure status.

      (c)      A carrier that uses a provider panel:

            (1)      on request, shall provide an application and information that relates to consideration for participation on the carrier's provider panel to any provider seeking to apply for participation;

            (2)      shall make publicly available its application; and

            (3)      shall make efforts to increase the opportunity for a broad range of minority providers to participate on the carrier's provider panel.

      (d)      (1)      A provider that seeks to participate on a provider panel of a carrier shall submit an application to the carrier.

            (2)      (i)      Subject to paragraph (3) of this subsection, the carrier, after reviewing the application, shall accept or reject the provider for participation on the carrier's provider panel.

                  (ii)      If the carrier rejects the provider for participation on the carrier's provider panel, the carrier shall send to the provider at the address listed in the application written notice of the rejection.

            (3)      (i)      Except as provided in paragraph (4) of this subsection, within 30 days after the date a carrier receives a completed application, the carrier shall send to the provider at the address listed in the application written notice of:

                        1.      the carrier's intent to continue to process the provider's application to obtain necessary credentialing information; or

                        2.      the carrier's rejection of the provider for participation on the carrier's provider panel.

                  (ii)      The failure of a carrier to provide the notice required under subparagraph (i) of this paragraph is a violation of this article and the carrier is subject to the penalties provided by § 4-113(d) of this article.

                  (iii)      If, under subparagraph (i)1 of this paragraph, a carrier provides notice to the provider of its intent to continue to process the provider's application to obtain necessary credentialing information, the carrier, within 150 days after the date the notice is provided, shall:

                        1.      accept or reject the provider for participation on the carrier's provider panel; and

                        2.      send written notice of the acceptance or rejection to the provider at the address listed in the application.

                  (iv)      The failure of a carrier to provide the notice required under subparagraph (iii)2 of this paragraph is a violation of this article and the carrier is subject to the provisions of and penalties provided by §§ 4-113 and 4-114 of this article.

            (4)      (i)      A carrier that receives an incomplete application shall return the application to the provider at the address listed in the application within 10 days after the date the application is received.

                  (ii)      The carrier shall indicate to the provider what information is needed to make the application complete.

                  (iii)      The provider may return the completed application to the carrier.

                  (iv)      After the carrier receives the completed application, the carrier is subject to the time periods established in paragraph (3) of this subsection.

            (5)      A carrier may charge a reasonable fee for an application submitted to the carrier under this section.

      (e)      A carrier may not deny an application for participation or terminate participation on its provider panel on the basis of:

            (1)      gender, race, age, religion, national origin, or a protected category under the federal Americans with Disabilities Act;

            (2)      the type or number of appeals that the provider files under Subtitle 10B of this title;

            (3)      the number of grievances or complaints that the provider files on behalf of a patient under Subtitle 10A of this title; or

            (4)      the type or number of complaints or grievances that the provider files or requests for review under the carrier's internal review system established under subsection (h) of this section.

      (f)      (1)      A carrier may not deny an application for participation or terminate participation on its provider panel solely on the basis of the license, certification, or other authorization of the provider to provide health care services if the carrier provides health care services within the provider's lawful scope of practice.

            (2)      Notwithstanding paragraph (1) of this subsection, a carrier may reject an application for participation or terminate participation on its provider panel based on the participation on the provider panel of a sufficient number of similarly qualified providers.

            (3)      A violation of this subsection does not create a new cause of action.

      (g)      A carrier may not terminate participation on its provider panel or otherwise penalize a provider for:

            (1)      advocating the interests of a patient through the carrier's internal review system established under subsection (h) of this section;

            (2)      filing an appeal under Subtitle 10B of this title; or

            (3)      filing a grievance or complaint on behalf of a patient under Subtitle 10A of this title.

      (h)      Each carrier shall establish an internal review system to resolve grievances initiated by providers that participate on the carrier's provider panel, including grievances involving the termination of a provider from participation on the carrier's provider panel.

      (i)      (1)      For at least 90 days after the date of the notice of termination of a primary care provider from a carrier's provider panel for reasons unrelated to fraud, patient abuse, incompetency, or loss of licensure status, the primary care provider shall furnish health care services to each enrollee:

                  (i)      who was receiving health care services from the primary care provider before the notice of termination; and

                  (ii)      who, after receiving notice under subsection (b) of this section of the termination of the primary care provider, requests to continue receiving health care services from the primary care provider.

            (2)      A carrier shall reimburse a primary care provider that furnishes health care services under this subsection in accordance with the primary care provider's agreement with the carrier.

      (j)      (1)      A carrier shall make available to prospective enrollees on the Internet and, on request of a prospective enrollee, in printed form:

                  (i)      a list of providers on the carrier's provider panel; and

                  (ii)      information on providers that are no longer accepting new patients.

            (2)      A carrier shall notify each enrollee at the time of initial enrollment and renewal about how to obtain the following information on the Internet and in printed form:

                  (i)      a list of providers on the carrier's provider panel; and

                  (ii)      information on providers that are no longer accepting new patients.

            (3)      (i)      Information provided in printed form under paragraphs (1) and (2) of this subsection shall be updated at least once a year.

                  (ii)      Information provided on the Internet under paragraphs (1) and (2) of this subsection shall be updated at least once every 15 days.

            (4)      A policy, certificate, or other evidence of coverage shall:

                  (i)      indicate clearly the office in the Administration that is responsible for receiving and responding to complaints from enrollees about carriers; and

                  (ii)      include the telephone number of the office and the procedure for filing a complaint.

      (k)      The Commissioner:

            (1)      shall adopt regulations that relate to the procedures that carriers must use to process applications for participation on a provider panel; and

            (2)      in consultation with the Secretary of Health and Mental Hygiene, shall adopt strategies to assist carriers in maximizing the opportunity for a broad range of minority providers to participate in the delivery of health care services.

      (l)      (1)      (i)      In this subsection the following words have the meanings indicated.

                  (ii)      1.      "Health benefit plan" has the meaning stated in § 15-1201 of this title.

                        2.      "Health benefit plan" includes dental plans and other health benefit plans that contract with dentists to offer dental care services.

                  (iii)      "Provider panel" includes an arrangement in which any provider may participate solely by contracting with the carrier to provide health care services at a discounted fee-for-service rate.

            (2)      Except as provided in paragraph (3) of this subsection, a carrier that offers coverage for health care services through one or more health benefit plans or contracts with providers to offer health care services through one or more provider panels may not require a provider, as a condition of participation or continuation on a provider panel for one health benefit plan of a carrier, to serve also on a provider panel of another health benefit plan of the carrier.

            (3)      Subject to § 15-102.5 of the Health - General Article, a carrier that offers health care services as a managed care organization as defined under § 15-101(e) of the Health - General Article, may require a provider, as a condition of participation on a provider panel for one or more health benefit plans of the carrier, to serve on a provider panel of the managed care organization.

            (4)      If a provider elects to terminate participation on the provider panel of a health benefit plan, the provider shall:

                  (i)      notify the carrier at least 90 days before the date of termination; and

                  (ii)      for at least 90 days after the date of the notice of termination, continue to furnish health care services to an enrollee of the carrier for whom the provider was responsible for the delivery of health care services prior to the notice of termination.