WILLIAM DONALD SCHAEFER, Governor Ch. 388

(f) "Member" means a person who makes a contract or on
whose behalf a contract is made with a health maintenance
organization for health care services.

(h) "Subscriber" means a person who makes a contract with a
health maintenance organization, either directly or through an
insurer or marketing organization, under which the person or
other designated persons are entitled to the health care
services.

19-705.2.

(A)  WITH THE ADVICE OF THE COMMISSIONER, THE SECRETARY
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)  THE COMPLAINT SYSTEM SHALL INCLUDE:

(1)  A PROCEDURE FOR ACKNOWLEDGING THE TIMELY
ACKNOWLEDGEMENT OF RECEIPT OF A COMPLAINT WITHIN 30 DAYS;

(2)  CRITERIA FOR DETERMINING THE APPROPRIATE LEVEL OF
INVESTIGATION FOR A COMPLAINT CONCERNING QUALITY OF CARE; AND ,
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 TO THE COMMISSIONER
OF ALL COMPLAINTS, OTHER THAN QUALITY OF CARE COMPLAINTS, FOR AN
APPROPRIATE INVESTIGATION.

(C)  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.

(C) (D) 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.

SECTION 2. AND BE IT FURTHER ENACTED, That:

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