2013 Maryland Code
HEALTH - GENERAL
§ 19-712 - Powers and authority of health maintenance organization

§19-712.

(a) Subject to the provisions of subsection (b) of this section, a person who holds a certificate of authority to operate a health maintenance organization under this subtitle may:

(1) Exercise the power that professional and other corporations, partnerships, associations, or other business entities have under their organizational documents and any laws of this State that do not conflict with this subtitle;

(2) Provide health care services to nonmembers who present themselves on other than a prepaid basis;

(3) Provide health care services on a prepaid basis through licensed providers of these services who are under contract with or employed by the health maintenance organization;

(4) Contract with any person to perform, on behalf of the health maintenance organization, functions such as marketing, enrollment, and administration;

(5) Contract for insurance, reinsurance, or indemnity or reimbursement against the cost of health care services provided by the health maintenance organization with:

(i) Any insurance company licensed to do health business in this State; or

(ii) Any hospital, nonprofit health service plan, medical health service, nursing service, optometric service, podiatry service, dental service, pharmaceutical service plan corporation, or similar entity authorized to do business in this State;

(6) Accept from government or private agencies payments that cover all or part of the cost of subscriptions to provide health care services, facilities, appliances, medicines, and supplies;

(7) Buy, lease, construct, renovate, operate, or maintain:

(i) A hospital, medical facility, and ancillary equipment; and

(ii) Property that is reasonably required for its principal office or for any other purpose necessary in the business of the health maintenance organization; and

(8) Offer indemnity benefits that cover out-of-area and emergency services.

(b) (1) A person who holds a certificate of authority to operate a health maintenance organization under this subtitle and who enters into any administrative service provider contract, as defined in § 19-713.2 of this subtitle, with a person or entity for the provision of health care services to subscribers shall be responsible for all claims or payments for health care services:

(i) Covered under the subscriber’s contract; and

(ii) Rendered by a provider, who is not the person or entity which entered into the administrative service provider contract with the health maintenance organization, pursuant to a referral by a person or entity which entered into the administrative service provider contract with the health maintenance organization.

(2) Responsibility for claims and payments under this subsection is subject to the provisions of § 15-1005 of the Insurance Article.

(c) The responsibility of a health maintenance organization for claims or payments for health care services in accordance with subsection (b) of this section under an administrative service provider contract:

(1) Is not limited by the amount in a segregated fund established under § 19-713.2 of this subtitle;

(2) Exists irrespective of the insolvency or other inability or failure of a contracting provider, as defined in § 19-713.2 of this subtitle, to pay;

(3) Exists irrespective of the delegation or further subcontracting of health care services by a contracting provider to an external provider, as defined in § 19-713.2 of this subtitle;

(4) May not be altered by contract; and

(5) Applies to all health care services, including those provided under State and federal programs, unless preempted by federal law.

(d) Subsections (b) and (c) of this section apply to a contract between a health maintenance organization and any company affiliated with the health maintenance organization through common ownership within an insurance holding company system, that meets the definition of a contracting provider under § 19-713.2 of this subtitle.

§ 19-712 - 1. Reimbursement to provider

Repealed by Acts 1999, ch. 472, § 1, effective October 1, 1999.

§ 19-712 - 2. Notice to pharmacies of change in pharmaceutical benefits

(a) Notice of change. -- A health maintenance organization that provides pharmaceutical benefits shall notify all pharmacies under contract with the health maintenance organization in writing of changes in the pharmaceutical benefit program rules or requirements at least 30 days before the change is effective.

(b) Changes that require notice. -- Changes that require 30 days' advance written notice under subsection (a) of this section are:

(1) Exclusion of coverage for classes of drugs as specified by contract;

(2) Changes in prior or preauthorization procedures; and

(3) Selection of new prescription claims processors.

(c) Failure to provide notice. -- A health maintenance organization that fails to provide advance notice as required under subsection (a) of this section shall honor and pay in full any claim under the program rules or requirements that existed before the change for 30 days after the postmarked date of the notice.

§ 19-712 - 3. Uniform claims forms

Repealed by Acts 2000, ch. 410, effective June 1, 2000.

§ 19-712 - 4. Prohibited referrals

(a) Definitions. -- In this section the terms "health care practitioner", "health care entity", and "health care service" have the same meanings as provided in § 1-301 of the Health Occupations Article.

(b) Repayments. -- A health maintenance organization may seek repayment from a health care practitioner of any moneys paid for any claim, bill, or other demand or request for payment for the health care services that were determined by the appropriate regulatory licensing board to be furnished as a result of a referral prohibited by § 1-302 of the Health Occupations Article.

(c) Contract provision excluding payment authorized. -- Every contract between a health maintenance organization and its subscribers or a group of subscribers for the provision of health care services shall include a provision excluding payment of any claim, bill, or other demand or request for payment for health care services determined to be furnished as a result of a referral prohibited by § 1-302 of the Health Occupations Article.

(d) Report of pattern of claims. -- A health maintenance organization subject to the provisions of this section shall report to the Commissioner and the appropriate regulatory board any pattern of claims, bills or other demands or requests for payment submitted for a health care service provided as a result of a referral prohibited by § 1-302 of the Health Occupations Article within 30 days after that health maintenance organization has knowledge of that pattern.

(e) Audit or investigation not required. --

(1) Notwithstanding the provisions of this section, a health maintenance organization reimbursing for health care services is not required to audit or investigate any claim, bill, or other demand or request for payment for the purpose of determining whether those services were the result of a prohibited referral.

(2) Any audit or investigation of any claim, bill, or other demand or request for payment for the purpose of determining whether those services were the result of the prohibited referral are not grounds to delay payment or waive the provisions of § 15-1005 of the Insurance Article.

(f) Refunds. -- For any claim, bill, or request for payment that is paid and is subsequently determined to be the result of a prohibited referral, a health maintenance organization may seek a refund of that payment in accordance with the provisions of § 1-305 of the Health Occupations Article.

§ 19-712 - 5. Reimbursement for hospital emergency facility and provider

(a) Medically necessary services -- Authorization by health maintenance organization. -- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medically necessary services provided to a member or subscriber of the health maintenance organization if the health maintenance organization authorized, directed, referred, or otherwise allowed the member or subscriber to use the emergency facility and the medically necessary services are related to the condition for which the member was allowed to use the emergency facility.

(b) Medically necessary services -- Failure to provide 24-hour access. -- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medically necessary services that relate to the condition presented and that are provided by the provider in the emergency facility to a member or subscriber of the health maintenance organization if the health maintenance organization fails to provide 24-hour access in accordance with the standards of quality of care required under § 19-705.1(b)(1)(ii) of this subtitle.

(c) Medical screening services pursuant to federal act. -- A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medical screening, assessment, and stabilization services rendered to meet the requirements of the federal Emergency Medical Treatment and Active Labor Act.

(d) Prior authorization or approval for payment. -- Notwithstanding any other provision of this subtitle, a provider may not be required to obtain prior authorization or approval for payment from a health maintenance organization in order to obtain reimbursement under subsection (a), (b), or (c) of this section.

(e) Payments from member or subscriber for nonemergency. -- Notwithstanding any other provision of this article, a hospital emergency facility or provider or a health maintenance organization that has reimbursed a provider may collect or attempt to collect payment from a member or subscriber for health care services provided for a medical condition that is determined not to be an emergency as defined in § 19-701 (e) of this subtitle.

(f) Follow-up care. -- If a health maintenance organization authorizes, directs, refers, or otherwise allows a member or subscriber to access a hospital emergency facility or other urgent care facility for a medical condition that requires emergency surgery, the health maintenance organization:

(1) Shall reimburse the physician, oral surgeon, periodontist, or podiatrist, who performed the surgical procedure, for follow-up care that is:

(i) Medically necessary;

(ii) Directly related to the condition for which the surgical procedure was performed; and

(iii) Provided in consultation with the member's or subscriber's primary care physician; and

(2) May not impose on the member or subscriber any co-payment or other cost-sharing requirement for any follow-up care that exceeds what a member or subscriber is required to pay for services rendered by a physician, oral surgeon, periodontist, or podiatrist who is a member of the provider panel of the health maintenance organization.

§ 19-712 - 6. Continuing care facility

(a) Medicare skilled nursing facility. -- Whenever a subscriber or an enrollee of a health maintenance organization is a resident of a continuing care facility that is regulated under Title 10, Subtitle 4 of the Human Services Article and received health care services in an acute care health care facility, the resident's primary care physician shall refer, if medically appropriate, the resident to the skilled nursing unit at the resident's continuing care facility for the provision of health care services included in the resident's health maintenance organization Medicare contract if:

(1) The primary care physician and the resident or the designated representative of the resident do not choose an alternative course of treatment;

(2) The continuing care facility becomes a contracting provider in accordance with the health maintenance organization's standard terms and conditions for its participating providers and meets the credentialing criteria for becoming a participating provider;

(3) The continuing care facility meets all the guidelines established by the Division of Licensing and Certification of the Department, including Medicare certification; and

(4) The continuing care facility's skilled nursing unit is certified as a Medicare skilled nursing facility.

(b) Residents; advertising. --

(1) The continuing care facility is not obligated to accept for the provision of health care services anyone other than a resident of the continuing care facility.

(2) The health maintenance organization and the continuing care facility are not obligated to advertise in any manner that the continuing care facility is a participating provider with respect to coverage offered by the health maintenance organization for Medicare benefits or other treatment in the skilled nursing unit for anyone other than residents of the continuing care facility.

§ 19-712 - 7. Reimbursement to community health resources.

To the extent required under federal law, a health maintenance organization shall reimburse a community health resource, as defined in § 19-2101 of this title, for covered services provided to a member or subscriber of the Health Maintenance Organization.