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S.B. 164
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VETOES
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(k) Each carrier shall include the information required by subsections (f) and
[(i)(2)(iii)] (I) SUBSECTION (F)(2)(III), (IV), AND (V) of this section in the policy, plan,
certificate, enrollment materials, or other evidence of coverage that the carrier
provides to a member at the time of the member's initial coverage or renewal of
coverage.
SECTION 2. AND BE IT FURTHER ENACTED, That the Laws of Maryland
read as follows:
SUBTITLE 10D. COMPLAINT PROCESS FOR COVERAGE DECISIONS.
15-10D-01.
(A) IN THIS SUBTITLE THE FOLLOWING WORDS HAVE THE MEANINGS
INDICATED.
(B) "APPEAL" MEANS A PROTEST FILED BY A MEMBER OR A HEALTH CARE
PROVIDER WITH A CARRIER UNDER ITS INTERNAL APPEAL PROCESS REGARDING A
COVERAGE DECISION CONCERNING A MEMBER
(C) "APPEAL DECISION" MEANS A FINAL DETERMINATION BY A CARRIER THAT
ARISES FROM AN APPEAL FILED WITH THE CARRIER UNDER ITS APPEAL PROCESS
REGARDING A COVERAGE DECISION CONCERNING A MEMBER.
(D) "CARRIER" MEANS A PERSON THAT OFFERS A HEALTH CARE SERVICES
BENEFIT PLAN AND IS:
(1) AN AUTHORIZED INSURER THAT PROVIDES HEALTH INSURANCE IN
THE STATE;
(2) A NONPROFIT HEALTH SERVICE PLAN;
(3) A HEALTH MAINTENANCE ORGANIZATION;
(4) A DENTAL PLAN ORGANIZATION; OR
(5) EXCEPT FOR A MANAGED CARE ORGANIZATION, AS DEFINED IN
TITLE 15, SUBTITLE 1 OF THE HEALTH - GENERAL ARTICLE, ANY OTHER PERSON
THAT PROVIDES OFFERS A HEALTH CARE SERVICES BENEFIT PLAN SUBJECT TO
REGULATION BY THE STATE.
(E) "COMPLAINT" MEANS A PROTEST FILED WITH THE COMMISSIONER
INVOLVING A COVERAGE DECISION NOT TO PAY A CLAIM FOR HEALTH CARE
SERVICES OTHER THAN THAT WHICH IS COVERED BY SUBTITLE 10A OF THIS TITLE.
(F) (1) "COVERAGE DECISION" MEANS A FINAL AN INITIAL DETERMINATION
BY A CARRIER OR A REPRESENTATIVE OF THE CARRIER THAT RESULTS IN
NONCOVERAGE OF A HEALTH CARE SERVICE.
(2) "COVERAGE DECISION" INCLUDES PAYMENT NONPAYMENT OF ALL
OR ANY PART OF A CLAIM.
(3) "COVERAGE DECISION" DOES NOT INCLUDE AN ADVERSE DECISION
AS DEFINED IN § 15-10A-01(B) OF THIS TITLE.
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- 3734 -
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