2013 Maryland Code
HEALTH - GENERAL
§ 19-703 - Scope of subtitle [Subject to amendment effective January 1, 2014; amended version follows this section].

§19-703.

(a) This subtitle does not:

(1) Authorize any person to engage directly or indirectly in the practice of any health occupation except as otherwise authorized by law;

(2) Authorize any person to regulate, interfere, or intervene in the relationship between any provider of health care services and the patients of the provider; or

(3) Prohibit any health maintenance organization from meeting the requirements of any federal law that authorizes the health maintenance organization to:

(i) Receive federal financial assistance; or

(ii) Enroll beneficiaries assisted by federal funds.

(b) A health maintenance organization or a part of it that is also a community health center organized under the federal Public Health Service Act and receives federal funds under 42 U.S.C. § 254c is not required to provide hospitalization for individuals for whom services are provided by those funds.

(c) Health maintenance organizations shall offer as an option to all of their members or subscribers benefits for hospice services provided by a hospice care program, as defined in § 19-901(c) of this title.

(d) Health maintenance organizations shall provide continuation coverage required under §§ 15-407 through 15-409 of the Insurance Article.

(e) (1) Notwithstanding any other provision of this subtitle, a health maintenance organization may offer a benefit package that provides at a minimum benefits required by former Article 48A, § 490-O for a limited benefits policy.

(2) A benefit package offered under paragraph (1) of this subsection shall:

(i) Be subject to the approval of the Insurance Commissioner; and

(ii) Satisfy the requirements of former Article 48A, § 490-O.

(f) Notwithstanding any other provision of this subtitle, a health maintenance organization may provide a limited set of health benefits if the limited set of health benefits is for subscribers or members who are enrolled in a county program to provide health care services for low-income individuals.

(g) (1) In addition to the requirements of § 19-706(i) of this subtitle and § 15-10B-09 of the Insurance Article, whenever a mother is required to remain hospitalized after childbirth for medical reasons and the mother requests that the newborn remain in the hospital, a health maintenance organization shall provide as part of its hospitalization services provided to members and subscribers payment for the cost of additional hospitalization for the newborn for up to 4 days.

(2) The attending physician or certified nurse midwife of the mother, or the designee of the attending physician or certified nurse midwife, shall provide notice to the mother of the provisions of paragraph (1) of this subsection.

§ 19-703 - Scope of subtitle (Effective January 1, 2014)

(a) In general. -- This subtitle does not:

(1) Authorize any person to engage directly or indirectly in the practice of any health occupation except as otherwise authorized by law;

(2) Authorize any person to regulate, interfere, or intervene in the relationship between any provider of health care services and the patients of the provider; or

(3) Prohibit any health maintenance organization from meeting the requirements of any federal law that authorizes the health maintenance organization to:

(i) Receive federal financial assistance; or

(ii) Enroll beneficiaries assisted by federal funds.

(b) Hospitalization services. -- A health maintenance organization or a part of it that is also a community health center organized under the federal Public Health Service Act and receives federal funds under 42 U.S.C. § 254c is not required to provide hospitalization for individuals for whom services are provided by those funds.

(c) Benefits for hospice services. -- Health maintenance organizations shall offer as an option to all of their members or subscribers benefits for hospice services provided by a hospice care program, as defined in § 19-901 (c) of this title.

(d) Coverage for surviving spouses. -- Health maintenance organizations shall provide continuation coverage required under §§ 15-407 through 15-409 of the Insurance Article.

(e) Limited benefits for low-income individuals. -- Notwithstanding any other provision of this subtitle, a health maintenance organization may provide a limited set of health benefits if the limited set of health benefits is for subscribers or members who are enrolled in a county program to provide health care services for low-income individuals.

(f) Hospitalization benefits for newborns. --

(1) In addition to the requirements of § 19-706(i) of this subtitle and § 15-10B-09 of the Insurance Article, whenever a mother is required to remain hospitalized after childbirth for medical reasons and the mother requests that the newborn remain in the hospital, a health maintenance organization shall provide as part of its hospitalization services provided to members and subscribers payment for the cost of additional hospitalization for the newborn for up to 4 days.

(2) The attending physician or certified nurse midwife of the mother, or the designee of the attending physician or certified nurse midwife, shall provide notice to the mother of the provisions of paragraph (1) of this subsection.

§ 19-703 - 1. Discrimination relating to mental illness, emotional disorders, or substance abuse

(a) Definitions. --

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

(2) "Alcohol abuse" has the meaning stated in § 8-101 of this article.

(3) "Drug abuse" has the meaning stated in § 8-101 of this article.

(4) "Health benefit plan" has the meaning stated in § 15-1401 of the Insurance Article.

(5) "Large employer" means an employer that has more than 50 employees and is not a small employer.

(6) "Managed care system" means a method that a carrier uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality, and claims.

(7) "Partial hospitalization" means the provision of medically directed intensive or intermediate short-term treatment for mental illness, emotional disorders, drug abuse or alcohol abuse for a period of less than 24 hours but more than 4 hours in a day for a member or subscriber in a licensed or certified facility or program.

(8) "Small employer" means an employer that:

(i) Employed an average of at least two, but not more than 50 employees on business days during the preceding calendar year; and

(ii) Employs at least two employees on the first day of the plan year.

(b) Prohibition of discrimination; discrimination per se. --

(1) Subject to the provisions of this section, each contract or certificate issued to a member or subscriber by a health maintenance organization that provides health benefits and services for diseases may not discriminate against any person with a mental illness, emotional disorder or a drug abuse or alcohol abuse disorder by failing to provide benefits for treatment and diagnosis of these illnesses under the same terms and conditions as provided for covered benefits offered under the contract or certificate for the treatment of physical illness.

(2) It shall not be considered to be discriminatory under paragraph (1) of this subsection if at least the following benefits are provided:

(i) With respect to inpatient benefits provided in a licensed or certified facility, which shall include hospital inpatient benefits, the total number of days for which benefits are payable shall be at least equal to the same terms and conditions that apply to the benefits available under the contract or certificate for physical illness;

(ii) Except as provided in item (iii) of this paragraph and subject to subsection (e) of this section, with respect to benefits for partial hospitalization, at least 60 days of partial hospitalization shall be covered under the same terms and conditions that apply to the benefit available under the contract or certificate for physical illness;

(iii) For group contracts covering employees of one or more large employers, with respect to benefits for partial hospitalization for the treatment of mental illness, emotional disorders, drug abuse, and alcohol abuse, the greater of:

1. The same benefits payable under the contract for partial hospitalization for physical illness; or

2. At least 60 days of partial hospitalization covered under the same terms and conditions that apply to outpatient treatment of physical illnesses;

(iv) Except as provided in item (v) of this paragraph, with respect to outpatient coverage, other than for inpatient or partial hospitalization services, benefits for covered expenses arising from services, including psychological and neuropsychological testing for diagnostic purposes, that are rendered to treat mental illness, emotional disorders, drug abuse, and alcohol abuse shall be at a rate that is, after the applicable deductible, not less than:

1. 80 percent for the first 5 visits in any calendar year or benefit period of not more than 12 months;

2. 65 percent for the 6th through 30th visit in any calendar year or benefit period of not more than 12 months; and

3. 50 percent for the 31st visit and any visit after the 31st visit in any calendar year or benefit period of not more than 12 months; and

(v) For group contracts covering employees of one or more large employers, benefits for covered outpatient expenses arising from services, including all office visits and psychological and neuropsychological testing for diagnostic purposes, that are rendered to treat mental illness, emotional disorders, drug abuse, and alcohol abuse shall be covered under the same terms and conditions that apply to similar benefits available under the contract for physical illness.

(c) Eligible expenses. --

(1) The benefits under this section shall be required only for expenses arising for treatment of mental illnesses, emotional disorders, drug abuse, and alcohol abuse that in the professional judgment of practitioners is medically necessary and treatable.

(2) The benefits required under this section shall be provided as one set of benefits covering mental illnesses, emotional disorders, drug abuse, and alcohol abuse.

(3) Subject to paragraph (4) of this subsection, the benefits required under this section may be delivered under a managed care system.

(4) For group contracts covering employees of one or more large employers, the benefits required under this section may be delivered under a managed care system only if the benefits for physical illnesses covered under the contract are delivered under a managed care system.

(5) For group contracts covering employees of one or more large employers, the processes, strategies, evidentiary standards, or other factors used to manage the benefits required under this section must be comparable as written and in operation to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used to manage the benefits for physical illnesses covered under the contract.

(6) Except as specifically provided in this section, benefits for illnesses covered by this section and the benefits for physical illnesses covered under a contract or certificate shall have the same terms and conditions.

(7) Except for the coinsurance provisions in subsection (b)(2)(iv) of this section, a contract or certificate that is subject to this section may not have:

(i) Separate lifetime maximums for physical illnesses and illnesses covered under this section;

(ii) Separate deductibles and coinsurance amounts for physical illnesses and illnesses covered under this section; or

(iii) Separate out-of-pocket limits in a benefit period of not more than 12 months for physical illnesses and illnesses covered under this section.

(8) (i) Subject to subparagraph (ii) of this paragraph, any copayments required under a contract or certificate for benefits for illnesses covered under this section shall be:

1. Actuarially equivalent to any coinsurance requirements under this section; or

2. Where there are no coinsurance requirements, not greater than a copayment required for a benefit under the contract or a certificate for a physical illness.

(ii) A health maintenance organization may not charge a copayment that is greater than 50% of the daily cost for methadone maintenance treatment.

(d) Visits for medication management. -- An office visit to a physican or other health care provider for the purpose of medication management may not be counted against the number of visits required to be covered as a part of the benefits required under subsection (b)(2)(iv) of this section and shall be reimbursed under the same terms and conditions as an office visit for physical illnesses covered under the contract or certificate.

(e) Excess minimum benefits for necessary partial hospitalization. -- Nothing in this section shall be construed to prohibit exceeding the minimum benefits required under subsection (b)(2)(ii) or (iii) of this section for any partial hospitalization day that is medically necessary and would serve to prevent inpatient hospitalization.