PARRIS N. GLENDENING, Governor

Ch. 378

6. PROFESSIONAL OFFICE; OR

7. ANY OTHER ENTITY LICENSED OR AUTHORIZED BY LAW
TO PROVIDE OR DELIVER PROFESSIONAL HEALTH CARE SERVICES THROUGH OR
ON BEHALF OF A PROVIDER.

(8) "THERAPEUTIC SERVICES" MEANS ANY MEDICAL OR SURGICAL
SERVICE OR PROCEDURE THAT A PROVIDER CAN USE TO TREAT A HUMAN DISEASE
OR DISORDER.

(B) (1) THIS SECTION APPLIES TO ANY CARRIER THAT PROVIDES HEALTH
CARE SERVICES TO ENROLLEES OR OTHERWISE MAKES HEALTH CARE SERVICES
AVAILABLE TO ENROLLEES THROUGH CONTRACTS WITH PROVIDERS.

(2) THIS SECTION DOES NOT AFFECT THE RIGHT OF AN ENROLLEE TO
APPEAL ANY ADVERSE DECISION BY A CARRIER THROUGH THE CARRIER'S APPEALS
PROCESS.

(C) (1) A CARRIER SHALL DISCLOSE TO PROVIDERS, ENROLLEES, AND
PROSPECTIVE ENROLLEES THE CARRIER'S DEFINITION OF "EXPERIMENTAL
MEDICAL CARE", AS REQUIRED UNDER PARAGRAPH (2) OF THIS SUBSECTION.

(2) THE CARRIER SHALL DISCLOSE THE DEFINITION IN:

(I) CONTRACTS OFFERED TO PROVIDERS THAT MAY RENDER
DIRECT HEALTH CARE SERVICES TO THE ENROLLEES OF THE CARRIER; AND

(II) MARKETING MATERIALS AND ENROLLMENT MATERIALS OF
THE CARRIER THAT ARE PROVIDED TO CURRENT ENROLLEES AND PROSPECTIVE
ENROLLEES.

(3) THE DEFINITION SHALL INCLUDE THE GENERAL CRITERIA AND
PROCESS THAT THE CARRIER FOLLOWS FOR INDIVIDUAL ENROLLEES OR FOR THE
ENTIRE ENROLLED POPULATION IN EVALUATING WHETHER EMERGING MEDICAL
AND SURGICAL TREATMENTS WILL BE COVERED OR PAID FOR BY THE CARRIER.

(4) THE DEFINITION SHALL BE BINDING ON THE CARRIER, ENROLLEES,
AND PROVIDERS FOR THE PURPOSE OF RESOLVING DISPUTES THAT ARISE OVER
WHETHER A MEDICAL OR SURGICAL TREATMENT IS OR IS NOT EXPERIMENTAL,
AND THEREFORE, COVERED AND PAID FOR BY THE CARRIER.

(D) (1) EACH CARRIER SHALL ESTABLISH A SYSTEMATIC, SCIENTIFIC
PROCESS TO FOLLOW FOR EVALUATING EMERGING MEDICAL AND SURGICAL
TREATMENTS TO ENSURE THAT PROVIDERS AND ENROLLEES HAVE ACCESS TO THE
LATEST APPROPRIATE TREATMENTS.

(2) THE PROCESS SHALL INCLUDE:

(I) ONGOING ANALYSES BY THE MEDICAL DIRECTOR OF THE
CARRIER AND THE MEDICAL POLICY STAFF OF THE CARRIER OF PUBLISHED,
PEER-REVIEWED MEDICAL LITERATURE, AND THE FINDINGS AND PUBLICATIONS
OF STATE AND FEDERAL AGENCIES; AND

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