2013 Maryland Code
HEALTH - GENERAL
§ 15-101 - Definitions [Subject to amendment effective January 1, 2014; amended version follows this section]

§15-101.

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

(a-1) “Dental managed care organization” means a pre-paid dental plan that receives fees to manage dental services.

(a-2) “Dental services” means diagnostic, emergency, preventive, and therapeutic services for oral diseases.

(b) “Enrollee” means a program recipient who is enrolled in a managed care organization.

(b-1) “Expedited eligibility” means a streamlined eligibility process, conducted by the local health departments, for medical assistance for children and pregnant women under which an eligibility determination is made promptly, but not later than 10 working days after the date of application.

(c) “Facility” means a hospital or nursing facility including an intermediate care facility, skilled nursing facility, comprehensive care facility, or extended care facility.

(d) (1) “Historic provider” means a health care provider, as defined in § 19-132 of this article, or a residential service agency licensed under Title 19, Subtitle 4A of this article, that, on or before June 30, 1995, had a demonstrated history of providing services to program recipients, as defined by the Department in regulations.

(2) “Historic provider”, to the extent the provider meets the requirements in paragraph (1) of this subsection, shall include:

(i) A federal or State qualified community health center;

(ii) A provider with a program for the training of health care professionals, including an academic medical center;

(iii) A hospital outpatient program, physician, or advanced practice nurse that is a Maryland Access to Care (MAC) provider;

(iv) A local health department;

(v) A hospice, as defined in Title 19, Subtitle 9 of this article;

(vi) A pharmacy; and

(vii) Any other historic provider designated in accordance with regulations adopted by the Department.

(d-1) “Independent foster care adolescent” means an individual:

(1) Who is under 21 years of age; and

(2) Who, on the individual’s 18th birthday, was in foster care under the responsibility of the State.

(e) “Managed care organization” means:

(1) A certified health maintenance organization that is authorized to receive medical assistance prepaid capitation payments; or

(2) A corporation that:

(i) Is a managed care system that is authorized to receive medical assistance prepaid capitation payments;

(ii) Enrolls only program recipients or individuals or families served under the Maryland Children’s Health Program; and

(iii) Is subject to the requirements of § 15-102.4 of this subtitle.

(f) “Ombudsman program” means a program that assists enrollees in resolving disputes with managed care organizations in a timely manner and that is responsible, at a minimum, for the following functions:

(1) Investigating disputes between enrollees and managed care organizations referred by the enrollee hotline;

(2) Reporting to the Department:

(i) The resolution of all disputes;

(ii) A managed care organization’s failure to meet the Department’s requirements; and

(iii) Any other information specified by the Department;

(3) Educating enrollees about:

(i) The services provided by the enrollee’s managed care organization; and

(ii) The enrollee’s rights and responsibilities in receiving services from the managed care organization; and

(4) Advocating on behalf of the enrollee before the managed care organization, including assisting the enrollee in using the managed care organization’s grievance process.

(g) “Primary mental health services” means the clinical evaluation and assessment of services needed by an individual and the provision of services or referral for additional services as deemed medically appropriate by a primary care provider.

(h) “Program” means the Maryland Medical Assistance Program.

(i) “Program recipient” means an individual who receives benefits under the Program.

(j) “Specialty mental health services” means any mental health services other than primary mental health services.

§ 15-101 - Definitions (Effective January 1, 2014)

(a) In general. -- In this title the following words have the meanings indicated.

(a-1) Dental managed care organization. -- "Dental managed care organization" means a pre-paid dental plan that receives fees to manage dental services.

(a-2) Dental services. -- "Dental services" means diagnostic, emergency, preventive, and therapeutic services for oral diseases.

(b) Enrollee. -- "Enrollee" means a program recipient who is enrolled in a managed care organization.

(b-1) Expedited eligibility. -- "Expedited eligibility" means a streamlined eligibility process, conducted by the local health departments, for medical assistance for children and pregnant women under which an eligibility determination is made promptly, but not later than 10 working days after the date of application.

(c) Facility. -- "Facility" means a hospital or nursing facility including an intermediate care facility, skilled nursing facility, comprehensive care facility, or extended care facility.

(d) Historic provider. --

(1) "Historic provider" means a health care provider, as defined in § 19-132 of this article, or a residential service agency licensed under Title 19, Subtitle 4A of this article, that, on or before June 30, 1995, had a demonstrated history of providing services to program recipients, as defined by the Department in regulations.

(2) "Historic provider", to the extent the provider meets the requirements in paragraph (1) of this subsection, shall include:

(i) A federal or State qualified community health center;

(ii) A provider with a program for the training of health care professionals, including an academic medical center;

(iii) A hospital outpatient program, physician, or advanced practice nurse that is a Maryland Access to Care (MAC) provider;

(iv) A local health department;

(v) A hospice, as defined in Title 19, Subtitle 9 of this article;

(vi) A pharmacy; and

(vii) Any other historic provider designated in accordance with regulations adopted by the Department.

(d-1) Former foster care adolescent. -- "Former foster care adolescent" means an individual:

(1) Who is under 26 years of age; and

(2) Who, on the individual's 18th birthday, was in foster care under the responsibility of the State, any other state, or the District of Columbia.

(e) Managed care organization. -- "Managed care organization" means:

(1) A certified health maintenance organization that is authorized to receive medical assistance prepaid capitation payments; or

(2) A corporation that:

(i) Is a managed care system that is authorized to receive medical assistance prepaid capitation payments;

(ii) Enrolls only program recipients or individuals or families served under the Maryland Children's Health Program; and

(iii) Is subject to the requirements of § 15-102.4 of this subtitle.

(f) Ombudsman program. -- "Ombudsman program" means a program that assists enrollees in resolving disputes with managed care organizations in a timely manner and that is responsible, at a minimum, for the following functions:

(1) Investigating disputes between enrollees and managed care organizations referred by the enrollee hotline;

(2) Reporting to the Department:

(i) The resolution of all disputes;

(ii) A managed care organization's failure to meet the Department's requirements; and

(iii) Any other information specified by the Department;

(3) Educating enrollees about:

(i) The services provided by the enrollee's managed care organization; and

(ii) The enrollee's rights and responsibilities in receiving services from the managed care organization; and

(4) Advocating on behalf of the enrollee before the managed care organization, including assisting the enrollee in using the managed care organization's grievance process.

(g) Primary mental health services. -- "Primary mental health services" means the clinical evaluation and assessment of services needed by an individual and the provision of services or referral for additional services as deemed medically appropriate by a primary care provider.

(h) Program. -- "Program" means the Maryland Medical Assistance Program.

(i) Program recipient. -- "Program recipient" means an individual who receives benefits under the Program.

(j) Specialty mental health services. -- "Specialty mental health services" means any mental health services other than primary mental health services.

§ 15-101 - 1. Applicability of other provisions to a managed care organization [Subject to amendment effective January 1, 2014; amended version follows this section].

Except as otherwise provided in this subtitle, a managed care organization is not subject to the insurance laws of the State or to the provisions of Title 19 of this article.

§ 15-101 - 1. Applicability of other provisions to a managed care organization (Amendment effective January 1, 2014.)

(a) In general. -- Except as otherwise provided in this subtitle, a managed care organization is not subject to the insurance laws of the State or to the provisions of Title 19 of this article.

(b) Not required to offer qualified plan in Maryland Health Benefit Exchange. -- A managed care organization may not be required to offer a qualified plan, as defined in § 31-101 of the Insurance Article, in the Maryland Health Benefit Exchange.