Part J
HEALTH
MEDICAL ASSISTANCE
Maryland Children's Health Program
Chapter 110 of the 1998 Session created the Maryland Children's Health Program (Program). According to the Department of Health and Mental Hygiene (Department), as of April 14, 1998, Program enrollment stands at approximately 44,000 children. The Program extends coverage for comprehensive medical care and other health care services to children from birth up to the age of 19 whose family income is at or below 200% of the federal poverty level (FPL). Since the Program began on July 1, 1998, the Department has administered the Program through the Maryland Medicaid Managed Care Program (HealthChoice). However, beginning July 1, 1999, Chapter 110 required the Program to also be administered through employer sponsored health benefit plans and individual health benefit plans. All newly enrolled individuals would be required to enroll in an employer sponsored health benefit plan or an individual health benefit plan if: (1) the individual had dependent coverage available to them under a plan; (2) the Department had certified the plan as a qualified plan; and (3) the individual had a family income between 186 - 200% of the FPL. If any of these factors were not satisfied, the individual would be enrolled in the Program through HealthChoice.
The 1998 law also required, on or before July 1, 1999, for an individual who had a family income at or above 185% of the federal poverty level who was enrolled in the Program to pay a premium. The Department would develop the premium amount such that the cost of the premium is at least 1%, but does not exceed 2% of the annual family income. In addition, the Department was required to study and recommend programs to the General Assembly for expanding the availability of health insurance for children and their families through the private market.
The report studying the private option was prepared by the University of Maryland Baltimore County in consultation with a Technical Advisory Committee established by the Department. The Committee included representatives of the Maryland Insurance Administration, the Health Care Access and Cost Commission, the Maryland Health Care Foundation, the business community, and the health care insurance industry. According to the report, the Committee's major finding was that "it will be very difficult to provide employer sponsored or individual private health insurance for children from families with incomes between 185% and 200% of the federal poverty level given current State and federal requirements." Major factors leading to this conclusion included: (1) a very small target population which will fluctuate as family size and income change, presenting serious administrative complexities and actuarial risk; (2) a rich benefit package that is inconsistent with the private health insurance marketplace; (3) significant administrative costs for employers and the insurance industry; (4) the cost of collecting family contributions and making premium payments, which may exceed the amount of revenue generated by family contributions; and (5) a federal requirement that requires employers to contribute 60% of the cost of coverage.
Senate Bill 738 (passed) repeals
the requirement that the Department develop and implement a program to administer the
Program through employer sponsored or individual health benefit plans. The bill also
delays the requirement that the Department determine the schedule and method of collection
of the family contribution premium to July 1, 2000, and in doing so, requires the
Department to notify individuals of the requirements of the family contribution under the
Program before beginning the collection of the premium payment. The bill also directs the
Department, the Maryland Insurance Administration, the Heath Care Access and Cost
Commission, the business community, and the health care insurance industry to study
specific criteria regarding expanding the Program beyond current eligibility levels,
including:
Home and Community Based Services for Impaired Individuals
While approximately 70% of the State's Medicaid recipients are enrolled in the Maryland Medicaid Managed Care Program (HealthChoice), expenditures on services for HealthChoice enrollees account for only about 45% of the overall costs of the Program. Much of the remaining Medicaid spending is for long-term care for institutionalized individuals and certain individuals who are dually eligible for Medicaid and Medicare. Developing cost-effective methods for providing long-term care for these groups has become critical because of the continuous aging of the State's population. It is expected that from 1998 through 2020, the State's elderly population (age 60 and above) will increase from approximately 800,000 to 1.4 million, an increase of 75%.
Senate Bill 593 (passed) requires the Department of Health and Mental Hygiene (Department), on or before August 1, 1999, to apply to the federal Health Care Financing Administration for an amendment to the existing home and community-based services waiver to enable the State to receive federal matching funds for waiver services received by eligible "medically and functionally impaired" individuals participating in the waiver. A "medically and functionally impaired" individual is defined as an individual who is assessed by the Department to require services provided by a nursing facility, and who, but for the receipt of these services, would require admission to a nursing facility within 30 days. At a minimum, the services included in the State's waiver application must include assisted living, case management, personal care/homemaker, home health care, respite care, assistive technology, environmental modifications, ambulance and other transportation, medically necessary supplies, environmental assessments, family/consumer training, personal emergency response systems, home-delivered meals, and dietician/nutritionist.
The bill further directs the Department of Aging, the Department of Human Resources, and the Department to jointly administer the waiver services. The Department of Health and Mental Hygiene must adopt and implement regulations within 180 days after receiving federal approval of the amendment and must report to the General Assembly every six months on the status of the waiver application. On request by an individual who is eligible for waiver services, the Department is authorized to make an appropriate placement of the individual. Currently, in the absence of a waiver, individuals who could live in the community with appropriate support are forced into nursing homes to qualify for Medicaid funding. Under the bill, up to 7,500 individuals initially will qualify for authorized services, including no less than 2,500 assisted living program beds.
Assuming waiver approval and budget support to cover all the participants each year, expenditures for the Medicaid program would increase by $1.3 million in fiscal 2000, of which $650,000 is general funds and $650,000 is federal funds. Future year expenditures reflect annualization, increased participation, and inflation. General fund revenues would not be affected.
Federally Qualified Health Centers
The federal Balanced Budget Act of 1997 requires states to make supplemental payments to federally qualified health centers (FQHCs), on at least a quarterly basis, for the difference between the rates paid by a managed care organization (MCO) to a FQHC and the reasonable cost of FQHC services. Beginning in fiscal 2000, the difference begins to phase-down from 100%. The phase-down ends in fiscal 2003. Because Maryland had an approved Medicaid 1115 waiver on the date the Balanced Budget Act took effect, Maryland is not bound by the requirements of the Act. However, during the 1998 Session, the General Assembly enacted legislation reflecting the requirements of the Act. Chapters 434 and 435 required the Department of Health and Mental Hygiene (Department), in accordance with federal law, to pay to a FQHC the difference between the payment received by the FQHC from an MCO and the FQHC's reasonable cost in providing services to enrollees of the MCO.
Senate Bill 577/House Bill 660 (both passed) require the Department to work in conjunction with each FQHC to determine for the FQHC the reasonable cost of providing services to enrollees. Each FQHC must provide the Department with its enrollment and encounter data and its cost reports to assist the agency in making this reasonable cost calculation. The bills allow an FQHC to make a request at any time for the Department to review the payments made to the FQHC by an MCO. By October 1, 1999, the Department must establish in regulation a prospective rate for determining the reasonable costs of FQHCs in providing services. The use of a prospective rate is expected to simplify the current reimbursement process for the Department and the FQHCs. The rate will be developed by the Department, in consultation with the industry, and may vary depending on the size and location of the FQHC.
Specialty Mental Health Services
Under the Maryland Medicaid Managed Care Program (HealthChoice), the specialty mental health system is operated by the Mental Hygiene Administration of the Department of Health and Mental Hygiene. Services under the specialty mental health system are provided to individuals who require specialized mental health care beyond what a primary care provider can offer. The Mental Hygiene Administration has contracted with Maryland Health Partners, an administrative services organization, to perform utilization review and claims processing for the specialty mental health system.
In an effort to address the concerns of system providers regarding untimely reimbursement House Bill 923 (passed) requires that the current standards for prompt reimbursement of providers by health maintenance organizations also apply to the Medicaid specialty mental health system. Health maintenance organizations are required to reimburse providers for covered services within 30 days or pay interest at the rate of 1.5% per month unless there is a good faith dispute over the claim.
Medicaid Recoupment Under State Tobacco Settlement
As a result of the State Tobacco Settlement, Maryland could receive up to $690 million for the fiscal 2000 to 2004 period. However, the federal government could recoup 50% of Maryland's settlement payments. The federal government indicated in 1997 that it is entitled to part of any settlement the states reach with tobacco companies because the states were trying to recover Medicaid money spent on smoking-related illnesses. Senate Joint Resolution 1 (passed) urges Congress to enact and the President to sign legislation prohibiting the federal government from recouping any portion of the state tobacco settlement funds for the federal share of Medicaid expenditures. If the federal government decides to recoup its 50% share, Maryland would be required to remit $87.5 million and $61.3 million in fiscal 2000 and fiscal 2001, respectively. See Part A - Budget and State Aid for a more complete discussion of bills related to the Tobacco Settlement.
Interstate Compact on Adoption and Medical Assistance
According to the Department of Human Resources, a significant limitation on the effectiveness of Maryland's adoption assistance program has been the inability to assure prospective adoptive parents that they will receive the contemplated assistance, particularly medical assistance coverage, when they live in other states or move from Maryland to another state. The Interstate Compact on Adoption and Medical Assistance, which 36 states have joined, provides a mechanism for interstate assistance delivery. Senate Bill 96/House Bill 370 (both passed) allow Maryland to join the Compact.
Under the bills, a child with special needs who resides in this State and who is the subject of an adoption assistance agreement with another state is entitled to receive a Maryland medical assistance identification by filing with the Social Services Administration a certified copy of the adoption assistance agreement obtained from the adoption assistance state certifying the eligibility of the child for medical assistance. The adoptive family is required at least annually to show that the adoption assistance agreement is still in force or has been renewed. The Social Services Administration must treat the holder of a medical assistance identification obtained in this manner the same as other State recipients of medical assistance. The bills allow the State to provide medical assistance only for children under adoption assistance agreements from states that provide medical assistance to children with special needs under adoption assistance agreements made with Maryland. All other children entitled to medical assistance pursuant to adoption assistance agreements entered into by the State are eligible to receive the assistance in accordance with applicable laws and procedures.
SUBSTANCE ABUSE PROGRAMS
Alcohol and Drug Abuse Administration
The Alcohol and Drug Abuse Administration (ADAA) received almost $8.5 million in additional funding for expansion of local programs in fiscal 2000. The most significant funding increase of $3 million will cover the expansion of treatment programs in the areas with the greatest need. In addition, ADAA will use $1.6 million to support a new facility that provides inpatient and outpatient services for pregnant and postpartum women. Another $1.2 million will cover detoxification units in intermediate care facilities as well as 40 beds in intermediate care facilities in Southern Maryland. A facility operated jointly with the Mental Hygiene Administration will use $488,000 for treatment of court committed offenders with substance abuse and mental health problems. In a related program for offenders, the ADAA will expand treatment services in local detention centers with $480,000. Almost $1.7 million in federal funds will support the expansion of halfway houses, medication assisted therapy, and prevention programs for high-risk youth and college students.
Task Force to Study the Availability of Substance Abuse Programs
Chapter 778 of the 1998 Session established the Task Force to Study the Availability of Substance Abuse Programs. The Task Force is charged with developing a comprehensive strategy for increasing the funding and availability of substance abuse programs, examining the scope of the problem of substance abuse in the State and the number of programs that exist to address the problem, collecting data to determine any correlation between crime and substance abuse, and making recommendations to increase the availability of long and short term substance abuse programs. The Task Force was required to submit a final report to the General Assembly by January 1, 2000; however, due to the 1998 election, the Task Force was unable to meet. Senate Bill 206/House Bill 62 (both passed) extend by one year the life of and reporting date for the Task Force. The new termination date for the Task Force is December 31, 2000, with the final report due on January 1, 2001.
MISCELLANEOUS HEALTH PROGRAMS
Automated External Defibrillator Program
Senate Bill 294/House Bill 223 (both passed) establish an Automated External Defibrillator Program (Program) to be administered by the Emergency Medical Services (EMS) Board. The purpose of the Program is to provide a means for a facility to make automated external defibrillation available to resuscitate a person who is a victim of a sudden cardiac arrest when emergency medical services are not immediately available. Experience with similar programs indicates that the use of an automated external defibrillator increases an individual's chances of survival by 40%. Moreover, it is estimated that there are about 5,000 sudden cardiac arrests annually in Maryland, and that a 10-20% survival rate is possible if the affected person is treated with this device.
In developing the Program the EMS Board has authority to approve educational and training programs, to approve protocols for use, to inspect authorized facilities, and to delegate any of its authority to the Maryland Institute for Emergency Medical Services Systems. The EMS Board also has authority to issue and renew certificates; deny, suspend, or revoke or refuse to renew a certificate; issue a cease and desist order or obtain injunctive relief; and collect fees necessary for the administration of the Program.
Universal Newborn Hearing Screening
Currently, the Program for Hearing-Impaired Infants seeks early identification and follow-up of hearing-impaired infants and infants who have a risk factor of developing a hearing impairment. An "infant" is defined to be a child who is less than 1 year old. A "risk factor" would include: (1) spending more than 48 hours in a neonatal intensive care nursery; (2) anatomical malformations involving the head or neck; (3) severe asphyxia; (4) bacterial meningitis; (5) low birth weight; (6) congenital perinatal infection; and (7) family history of childhood hearing impairment. Questionnaires are used to identify high-risk infants, but a large percentage of the hearing-impaired population is not identified by the high-risk questionnaire. Some experts have indicated that hospitals fail to detect hearing problems in about half of the 420 babies born with hearing impairments in the State each year.
In an effort to enhance the early identification of infants who have actual or potential hearing impairments, Senate Bill 624/House Bill 884 (both passed) alter the existing Program to include the requirement that each "newborn" (newly defined to be a child up to 29 days old) who is born in or receives care in a Maryland hospital must be screened for hearing loss before discharge from a hospital. Screening for hearing loss is also to be included in the minimum child wellness services provided by insurers.
A hospital that provides obstetrical services is required to establish a program to screen all newborns for hearing loss before discharge. The program must consist of at least one of the following: (1) an auditory brainstem response test; (2) an otoacoustic emissions test; or (3) another test recommended by the Advisory Council for the Program and approved by the Department of Health and Mental Hygiene (Department). Results of hospital screening tests must be reported by the hospital to the Department, and the Department is required to develop methods to inform parents or guardians of newborns, and the infants' primary care providers, of the results of the hearing screening. Health maintenance organizations and managed care organizations must provide coverage for newborn hearing screening in hospitals before discharge. The bill also increases the membership of the existing Advisory Council to 11 members, and the qualifications of the physician and audiologist members of the Council are altered to ensure expertise in childhood hearing loss. Beginning October 1, 1999, the Department must work with the Advisory Council to adopt regulations and establish procedures in implementing the expanded Program. On July 1, 2000, the complete Program must be in operation.
Task Force on Food Allergies and Restaurant Patrons
To examine the concerns of, and problems encountered by, individuals with food allergies who eat in restaurants, House Bill 350 (passed) establishes a Task Force on Food Allergies and Restaurant Patrons. In consultation with the federal Food and Drug Administration, the Task Force is required to develop and report recommendations to the Governor and the General Assembly by December 1, 2000. According to the Food Allergy Network, the best way for people to manage food allergies is to strictly avoid foods to which they are allergic. Eating the "wrong" food could create an allergic reaction that causes hives, swelling, and even anaphylaxis (the swelling of the throat until it closes). It is important for people with food allergies to be able to know what ingredients are in the foods they are served. The provisions of the bill terminate on April 30, 2001.
MENTAL HEALTH
Mental Hygiene Administration Initiatives
The Mental Hygiene Administration (MHA) administers State programs and operates inpatient facilities for persons with mental illness. The fiscal 2000 budget contains four major programmatic changes in MHA. The institutional downsizing initiative, funded at $5.904 million, is intended to allow community based placements for 123 individuals who are currently served in MHA-operated residential facilities. The program is intended to grow to serving 164 individuals in fiscal 2001. The Targeted Case Management Services Program provides aggressive case management services for individuals identified as most likely to require hospitalization or those who have been hospitalized and are considered most likely to require rehospitalization. This year's expansion will increase service provision from an estimated 722 persons in fiscal 1998 to over 1,500 persons in fiscal 2000 and costs an additional $2.242 million in fiscal 2000.
The transitioning youth initiative is intended to serve youths with mental illness by providing a bridge from adolescence to adulthood through case management for planning, linkage, support, advocacy, and education facilitating transition to the community, supported employment, residential services, and mental health treatment. The fiscal 2000 budget includes $1.6 million to serve 80 people for six months. When fully phased in, the initiative will serve 579 individuals. Finally, the respite care initiative is designed to make respite care services more readily available within Maryland. Through the initiative it is hoped that out-of-home placements, hospitalization, and out-of-state placements can be reduced by offering respite from the stresses and demands which can overwhelm caregivers of children with serious emotional disturbance. The fiscal 2000 budget includes $588,000 to serve 350 children in seven different programs. When fully implemented, the initiative is expected to serve 1,050 children in 21 programs.
Exhibit 1 details the fiscal 2000 cost of the four programmatic changes in MHA and also the out-year cost of these initiatives. As Exhibit 1 shows, the $10.3 million fiscal 2000 cost is expected to grow to $35.5 million by fiscal 2004.
Consent of Minors to Mental Health Treatment
Current law provides that a minor who is 16 years old or older has the same capacity as an adult to consent to consultation, diagnosis, and treatment concerning a mental or emotional disorder by a physician or a clinic. House Bill 219 (passed) provides that the current legal capacity of a minor does not include the capacity to refuse treatment to which a parent, guardian, or custodian of the minor has given consent. The Mental Hygiene Administration reports that 16- and 17-year-old minors have recently been advised by a public law clinic that they may refuse treatment, which has created an awkward clinical situation when the minor's refusal is over the objection of a parent, guardian, or custodian.
Refusal of Psychiatric Medication
House Bill 64 (passed) extends to June 30, 2001, the termination date for current law concerning the administration of psychiatric medication to an individual without the individual's consent. Current law prohibits the administration of psychiatric medication to a nonconsenting individual unless (1) in an emergency, a physician deems it as a matter of danger to the life and safety of the individual; or (2) in a nonemergency, the individual is hospitalized involuntarily or committed for treatment by order of a court and the medication is approved by a clinical review panel in accordance with the provisions of law.
The statute amended by this bill was first enacted in 1990 and subsequently found to be unconstitutional by the Maryland Court of Appeals. In 1991, the law was amended to include patient safeguards, due process, and a two-year sunset provision. The sunset provision was extended for two additional years in 1993. In 1995, the sunset provision was extended for four more years until June 30, 1999, and the Department of Health and Mental Hygiene was required to submit a report to the Governor and the General Assembly with recommendations concerning the advisability of continuing this provision. The 1998 report of the Department's Mental Hygiene Administration recommended abrogation of the current termination date. The bill, however, extends this date for two additional years. The constitutionality of the current statute has been upheld by the courts.
CONTRACEPTION/ABORTION
Senate Bill 194 (failed), a reintroduction from the 1997 and 1998 Sessions, would have prohibited "partial-birth" abortions. A partial-birth abortion is a procedure performed 16 weeks after gestation in which the person performing the abortion partially delivers a living fetus through a vaginal breech presentation before killing the fetus and completing the delivery. Under the bill a person convicted of performing a "partial-birth" abortion is guilty of a misdemeanor and subject to a fine of $1,000 or imprisonment for not more than two years or both.
The bill would not have applied to a partial-birth abortion that is necessary to save the life of a mother whose life was endangered by a physical disorder, illness, or injury. Under certain circumstances, civil remedies against an individual who performs this procedure would have been available to the maternal grandparents of the fetus and the father married to the woman having a partial-birth abortion. Civil relief would have included damages for any physical or psychological injuries and damages equal to three times the cost of the partial-birth abortion. Physicians charged with an offense under the bill would have had a right to appeal to the Board of Physician Quality Assurance for a ruling on the necessity of the procedure. The bill specifically omitted imposing penalties on any woman upon whom a partial-birth abortion was performed.
The bill was modeled after federal legislation, the Partial-Birth Abortion Ban Act of 1997 (H.R. 1122), which passed the U.S. Congress but was vetoed by President Clinton on October 10, 1997. In his veto message, the President stated that the bill did not contain an exemption that would "adequately protect the lives and health of the small group of women in tragic circumstances who need an abortion performed at a late stage of pregnancy to avert death or serious injury."
Contraception
House Bill 94 (failed) would have repealed the right of a minor to consent to treatment for or advice about pregnancy and contraception. The bill also would have repealed immunity from liability for physicians, or persons working under the direction of a physician, from civil damages or criminal charges or disciplinary penalties because they treated a minor without parental, guardian, or custodial consent. Similar bills were introduced in 1997 and 1998 and were also unsuccessful.
TOBACCO
Cigarette Restitution Fund
Senate Bill 334/House Bill 751 (both passed) create the Cigarette Restitution Fund for payments received by the State from the tobacco settlement. Moneys in the fund can only be spent through appropriations in the annual State budget, and a minimum of $100 million or 90% of the funds available must be appropriated. In addition, 50% of the funds must be appropriated for programs with specific purposes. The health related purposes include: reducing the use of tobacco products by minors; public and school education campaigns with an emphasis on areas previously targeted by tobacco manufacturers' advertising; smoking cessation programs; purposes of the Maryland Health Care Foundation; primary health care in rural areas and areas previously targeted by tobacco manufacturers' advertising; prevention, treatment, and research, including capital projects, concerning cancer, heart disease, lung disease, and tobacco product use and control; and substance abuse treatment and prevention. A more extensive discussion of the tobacco settlement may be found in Part A - "Budgets and State Aid" of The 90 Day Report.
Access by Minors
The federal Food and Drug Administration (FDA) now regulates nicotine-containing cigarettes and smokeless tobacco as restricted devices under the Federal Food, Drug and Cosmetic Act. New regulations went into effect on February 28, 1997, which contain prohibitions against the sale of tobacco and restricted devices to minors. Most of these prohibitions have been struck down by lower court rulings. Still in effect, however, is the prohibition on sales to individuals under 18 years of age and the requirement of verification of a purchaser's age through photographic identification. The FDA is appealing all of these lower court cases. The issue of minors' access to tobacco products was again debated during the 1999 Session.
A study by the Office of the State Comptroller in July 1996 indicated that children were able to purchase tobacco products in the State 96% of the time. In an attempt to discourage access to tobacco products by minors, House Bill 163 (failed) would have prohibited a person from selling or offering for sale a tobacco product by means of a vending machine or other mechanical device used for dispensing tobacco products, except those machines or devices that accept only tokens and were in use on January 1, 1999. The bill did not apply to an establishment that is a bona fide fraternal or veterans organization.
Senate Bill 322 (failed) would have paid for the cost of converting existing vending machines to token use from revenues received by the State as a direct or indirect result of any judgment against or settlement with the tobacco industry.
Senate Bill 760 (failed) would have prohibited a person engaged in the business of selling or otherwise distributing tobacco paraphernalia for commercial purposes from distributing tobacco paraphernalia or a coupon redeemable for tobacco paraphernalia to minors. A convicted violator would have been guilty of a misdemeanor and subject to fines ranging from $300 for a first offense to $3,000 for a third offense within two years. Under the bill, minors generally would have been prohibited from possessing or purchasing tobacco paraphernalia and subject to civil proceedings in the Juvenile Court for violating this prohibition.
MISCELLANEOUS
Public Access to Ambient Air Monitoring Data
The Maryland Department of the Environment currently publishes information concerning ambient air monitoring data in a written annual air quality data report. Because the Internet has become such an effective information gathering tool, Senate Bill 323 (passed) requires the Department, beginning January 1, 2000, annually to post all validated ambient air monitoring data in the State on the Internet. This data may be provided in summary form and must include all validated ambient air monitoring data for the two most recent years for which data are available. Under the bill, this type of data consists of measured concentrations of air pollutants, including air pollutants for which there are no established ambient air quality standards or emission standards.
Community Services Reimbursement Rate Commission
Senate Bill 448 (passed) extends for three years the sunset on the Community Services Reimbursement Rate Commission. This Commission reviews rates paid to providers of services to individuals with developmental disabilities and mental illness. The bill also amends existing requirements concerning the appointment of members of the Commission, the frequency of its meetings, general powers, staffing, and reporting. The members of the Commission are limited to serving two consecutive terms and may not be reappointed for three years after their terms expire.
The Commission has largely met its initial statutory charge, which was principally based on the need to assess the adequacy of reimbursement rates paid to providers by the Developmental Disabilities Administration and the Mental Hygiene Administration. The bill provides the Commission with some new focus by altering the list of matters that this unit must consider. For example, the Commission must assess the extent and amount of uncompensated care delivered by providers, changes in reimbursement rates paid by the Department of Health and Mental Hygiene, the ability of providers to remain solvent, incentives and disincentives incorporated in rate setting methodologies and related alternatives, quality of care incentives through rate setting, and the adequacy of methods used to determine the annual cost of living adjustments to rates paid by the Developmental Disabilities Administration and the Mental Hygiene Administration. By October 1 of each year, the Commission must issue a report to the Governor, the Secretary of Health and Mental Hygiene, and the General Assembly with findings and recommendations concerning these matters.
HEALTH OCCUPATIONS GENERALLY
Accountability in a Managed Care Environment
The issue of whether the decision of a medical director should be subject to the oversight of the State Board of Physician Quality Assurance (BPQA) was a controversial subject during the 1998 Session of the General Assembly. During the 1998 Session, failed legislation would have provided that those who are responsible for medical or dental supervision or direction in health maintenance organizations, hospitals, ambulatory care facilities or other venues would be engaged in the practice of medicine and subject to the oversight of the State Board of Physician Quality Assurance and the State Board of Dental Examiners. The bills would have expanded the practice of medicine and dentistry to include medical or dental supervision and direction. During the 1998 Session, other failed legislation would have authorized the BPQA to discipline a physician medical director who is responsible for establishing or supervising protocols or procedures for a health care delivery system, such as a health maintenance organization.
Senate Bill 594/House Bill 243 (both failed) would have altered the definition of "the practice of medicine" to include, except for a determination made solely for an educational purpose, making a determination that a health care service, which an individual licensed or certified under Maryland law proposes for a patient, is not medically necessary or medically appropriate. The bills would have had the effect of subjecting a medical director to the oversight of the BPQA. Senate Bill 594 would have required the Maryland Insurance Administration (MIA), in consultation with the Department of Health and Mental Hygiene, to conduct a study on the potential impact the legislation would have on insurance premiums and access to insurance and the methods used by other states to address the necessity of medical decisions and procedures regarding HMOs.
Senate Bill 595/House Bill 594 (both failed) would have altered the definition of "practice of dentistry" in a manner identical to Senate Bill 594/House Bill 243 and would have subjected a dental director to the jurisdiction of the State Board of Dental Examiners. Senate Bill 595 would have also required the MIA to conduct the same study required under Senate Bill 594.
Scope of Practice - Prescriptive Authority
Current law authorizes physician assistants (PAs) to write medication orders, which are directives written in medical charts in hospitals, prisons, and public health clinics under written descriptions approved by the Board of Physician Quality Assurance (BPQA). Legislation passed during the 1999 Session expands the scope of practice of a PA.
House Bill 674 (passed) authorizes a physician to delegate to a PA the authority to exercise prescriptive authority under an approved delegation agreement. A supervising physician may not enter into more than two concurrent delegation agreements with PAs in a nonhospital setting. A physician may only delegate acts that are appropriate to education, training, and competence of the PA and may not delegate prescriptive authority to a PA for Schedule I controlled dangerous substances. A delegation agreement must be reviewed and approved by the BPQA and must contain attestations by the supervising physician regarding the physician's acceptance of responsibility for patient services and care rendered by the PA. The supervising physician must be available for consultation and must review and co-sign all prescribing activities of the PA. For patients being treated for chronic, life-threatening or degenerative conditions, the supervising physician must see these patients initially and as frequently as the patient's condition requires, but no less than within every five appointments or within 180 days, whichever occurs first. The BPQA must submit a list to the State Board of Pharmacy of all PAs who have prescriptive authority.
House Bill 936 (failed) would have permitted the State Board of Nursing to authorize a nurse psychotherapist to prescribe medications if the nurse psychotherapist submitted evidence of completion of a graduate course in psychopharmacology and physical assessment. The nurse psychotherapist would have had to secure approval from the State Board of Nursing and a written agreement from a physician. Currently, certified nurse practitioners and nurse midwives have prescriptive authority in limited settings.
NURSING
Multistate Licensure
Current law requires a nurse who is licensed in another state and wants to practice in Maryland to obtain a Maryland license. In 1997, the Assembly of State Boards of Nursing, with 57 of 61 state nursing boards present, unanimously adopted language for an interstate compact to establish mutual recognition licensure. Senate Bill 590/House Bill 429 (both passed) enable the State to join the Nurse Multistate Licensure Compact (Compact). This Compact allows nurses licensed in Maryland to practice in another state without having to obtain a license in the other state if the other state is a party to the Compact.
The Compact includes a statement of purpose, definition of terms, general provisions and jurisdiction and procedures for applying for licensure in a party state. The Compact also provides for handling of adverse practices, authority vested in a party state nursing board and the coordination of licensure information between all parties, as well as guidelines for program administration and the exchange of information regarding licensees. The bills also provide for immunity for state employees or agents of the state nurse licensing board, withdrawal from the Compact and dispute resolution between party states. The State Board of Nursing is also required to conduct a study to evaluate the effectiveness of the Compact and is required to report its findings to the Senate Economic and Environmental Affairs Committee and House Environmental Matters Committee on or before November 1, 2004.
As of April 14, 1999, Utah and Arkansas have passed legislation to enact the Compact. Legislation is pending in Nebraska, Texas, North Carolina, Wisconsin, and Iowa. Several other states have committed to introducing enabling legislation in the 2000 Session, including Arizona, Minnesota, Mississippi, South Dakota, New Jersey, and Idaho.
HEALTH CARE PROVIDERS
Physician Profiles
Under current law, the Board of Physician Quality Assurance (BPQA) is required to maintain, as a public record, a list of the public addresses of licensed physicians. The BPQA may maintain the nonpublic addresses of licensees which may not be publicly released. Senate Bill 302 (passed) expands the information available on physicians by requiring the BPQA to create a profile on each licensed physician. The profile must include a description of any final disciplinary action against the licensee taken by BPQA in the most recent ten years; description of any disciplinary action against the licensee taken by a licensing board in another jurisdiction in the most recent ten-year period; medical schools attended by the licensee and graduation date; the number of years in medical practice and a description of any medical specialties; the medical facilities where the licensee has privileges and the location of the primary practice setting; and whether the licensee participates in the Maryland Medical Assistance Program. The BPQA is required to forward a written profile to any person requesting a copy. In addition, all profiles must be publicly available on the Internet. Before profiles are made public, the BPQA must provide a reasonable opportunity to physicians to renew the profile and correct factual inaccuracies. The BPQA must include final disciplinary information on physicians within ten days after the action becomes final.
Mental Health Providers
Under current law, a civil cause of action may not arise against a "mental health care provider" or an "administrator" of a mental health facility for failing to predict, warn of, or take precautions to provide protection from a patient's violent behavior unless the provider knew of the patient's propensity to violence and the patient indicated through speech, writing or conduct of an intention to inflict imminent physical injury on a specified victim or group of victims. The duty to predict or warn may be discharged by seeking civil commitment of the patient, undertaking a documented treatment plan, or alerting a law enforcement agency and, if possible, the intended victims. Senate Bill 588 (Ch. 44) expands these provisions to any facility, corporation, partnership, association, or other entity that provides treatment or services to people with mental disorders. Accordingly, the protection provided under the law to individual mental health providers now applies to the facilities where they work and business entities with which they are affiliated.
Massage Therapists
Current law provides that an individual practicing massage therapy may be certified by the State Board of Chiropractic Examiners. In order to become certified, an individual, in addition to other statutory requirements, must complete at least 60 credit hours of higher education and 500 hours of education in a Board approved program. An individual who is not certified may still practice massage therapy but may not advertise that he/she is certified. The Board does not have jurisdiction over people who are not certified. Law enforcement officials have expressed concerns about illegal activities conducted under the guise of massage therapy. House Bill 178 (passed) extends Board jurisdiction to all people who claim to be massage therapists, whether certified or not by creating a classification of "registered massage practitioners" for individuals who practice nontherapeutic massage. A registered massage practitioner is a person practicing nontherapeutic massage professionally and for compensation in a setting that is not a health care facility. Eligible registrants must be of good moral character, at least 18 years old, must have completed 500 hours of education in a Board approved program, and must have passed an examination approved by the Board. No one may "practice massage therapy" or "practice nontherapeutic massage" unless either registered or certified by the Board.
To provide further protection for consumers, registered massage practitioners or business entities that employ registered massage practitioners may not claim or advertise to provide health-related therapeutic massage services. Furthermore, licensed or certified health care providers may refer patients only to certified massage therapists.
Chiropractors
Senate Bill 155/House Bill 646 (both passed) eliminate the requirement that an applicant for a chiropractic license must hold a bachelor's degree from a college or university prior to matriculation to an approved school of chiropractic.
HEALTH CARE FACILITIES AND REGULATION
HEALTH CARE REGULATORY REFORM
Generally
Health care regulation in Maryland has evolved over the last three decades into a highly-developed regulatory structure that incorporates the Department of Health and Mental Hygiene (DHMH), the Maryland Insurance Administration (MIA), and three independent commissions - the Health Resources Planning Commission (HRPC), the Health Services Cost Review Commission (HSCRC), and the Health Care Access and Cost Commission (HCACC). The annual cost of health care regulation by these agencies is approximately $22 million, supported by a combination of user fees, State general funds, and federal funds.
DHMH provides oversight for quality and services of facilities, practitioners, and health maintenance organizations. MIA regulates all aspects of insurance, including financial solvency for insurance carriers and health maintenance organizations, and contracts that insurers and health maintenance organizations enter into with providers and health consumers. HRPC oversees the needs of the health care system by considering access, quality, and efficiency issues as it adopts the State Health Plan, projects future State health care needs, and administers the certificate of need process. HSCRC regulates hospital rates and maintains the all-payor system. HCACC oversees the comprehensive standard health benefit plan established for the small group market in Maryland, the provider encounter data system, quality and performance report cards for health maintenance organizations, and other measures enacted under the Maryland Health Insurance Reform Act of 1993 (Chapter 9 of 1993) that are still under development, including provider practice parameters and the provider payment system.
Recent developments in health care delivery and financing, including the growth of managed care and the evolution of provider networks, have obscured the boundaries of the five regulatory agencies. Both health care provider and payor organizations have criticized the regulatory system for not keeping pace with developments in the industry.
Health Care Commission Consolidation
House Bill 995 (passed) consolidates two health care regulatory commissions and requires several studies. House Bill 995 abolishes the Health Resources Planning Commission (HRPC) and transfers its functions and funding to the Health Care Access and Cost Commission (HCACC). HCACC is renamed as the Maryland Health Care Commission (HCC). Funding for the HCC comes from a new Health Care Commission Fund, supported by user fees. The bill sets an annual limit of $8.25 million on HCC fee assessments and specifies the distribution of fees paid by hospitals, nursing homes, payors, and health care practitioners. The bill requires current health planning functions of HRPC and associated staff to be transferred to DHMH, except for those health planning functions necessary to support the certificate of need function, which are transferred to HCC with the rest of HRPC's functions. HCC is authorized to appoint advisory committees to make recommendations on community-based services, long term care, acute patient services, ambulatory surgical services, specialized health care services, residential treatment centers for children, and mental health and substance abuse services.
HCC is expanded to 13 members serving new staggered terms. For the initial terms, the bill requires: (1) 5 members to be appointed from among the current members of HCACC; (2) 5 members to be appointed from among the current members of HRPC; (3) 2 members to be payors; and (4) the chairman to be the current chairman of HCACC. Only 2 members may be physicians and 2 members may be payors.
The following studies are required under House Bill 995: (1) HCC and HSCRC, in consultation with DHMH and MIA, must submit a preliminary report by January 1, 2000, and a final report by July 1, 2000, on consolidating the two commissions and examining the certificate of need process, hospital rate regulation, and health planning; (2) HCC must submit a report by September 1, 2000 with recommendations on the appropriate level of HCC funding and user fee allocation; and (3 ) HCC must report on its plans for altering its permanent workforce.
Hospital Closures
According to the Health Resources Planning Commission, up to 41% of Maryland's 12,249 licensed acute care hospital beds will not be needed by the year 2000. Shorter hospital stays and less hospital utilization continue to push down hospital occupancy rates. Since 1980, the daily average hospital census in Maryland has dropped from 11,000 to 6,500, and that number is projected to drop to about 6,000 by the year 2000.
To provide funds for hospital closure costs, the Health Services Cost Review Commission (HSCRC) assesses a fee on hospitals which is paid to the Health and Higher Education Facilities Authority. The Authority issues bonds that help to pay for the hospital's closing costs. House Bill 994 (passed) facilitates the closing or downsizing of certain hospitals by broadening certificate of need exemptions, establishing a category of "limited service hospital," and providing for the delicensing of excess hospital beds and the financing of closing costs of a hospital that converts to a limited service hospital. Depending on which hospitals close or convert to limited service hospitals, which hospitals are used by patients, and whether payors pass on any realized cost-savings, the bill may result in lower State expenditures for the Medicaid program and the State Employee Health Benefits Plan.
Practice Parameters/Uniform Payment System
Responding to changes in the health care marketplace, House Bill 40 (failed) and House Bill 978 (Ch. 11) addresses the repeal of two responsibilities of the Health Care Access and Cost Commission (HCACC): the Advisory Committee on Practice Parameters and the uniform payment system for health care services.
HCACC was given the authority to develop practice parameters, with the assistance of the advisory council, in Chapter 9 of 1993. Practice parameters are defined as the appropriate clinical methods of treatment for individual procedures or diseases that are subject to a significant amount of medical malpractice litigation within a medical specialty area. A lack of acceptance by the physician community and the absence of a demonstrated usefulness led to HCACC's desire to eliminate the development of practice parameters. House Bill 978 repeals the requirement that HCACC foster the development of practice parameters and disbands the Advisory Committee on Practice Parameters. The fiscal 2000 budget includes $200,000 for the development of practice parameters; the enactment of House Bill 978 will result in an expenditure reduction of $200,000 beginning in fiscal 2000.
House Bill 40 would have repealed the authority of HCACC to develop a payment system for health care services and would have eliminated the requirement to implement a uniform payment system for all health care practitioners.
HEALTH CARE FACILITIES
Hospitals/Ambulatory Surgical Facilities
House Bill 705 (passed) authorizes the Health Care Access and Cost Commission to develop a report card for hospitals and ambulatory surgical facilities by July 1, 2001 and to contract with a private entity to develop the report card. The bill requires HCACC to consult with the Association of Maryland Hospitals and Health Systems, the Maryland Ambulatory Surgical Association, and other interested parties in developing a report card. House Bill 909 (passed) authorizes a hospital that has transferred certain outpatient services to an off-site facility prior to January 1, 1999 to elect to have these services subject to HSCRC hospital rate-setting and to be reimbursed by Medicaid at HSCRC-approved rates if certain conditions are met. This bill addresses concerns which arose when a Maryland hospital began to be reimbursed, because of a determination by the federal Health Care Financing Administration, at lower Medicare rates instead of HSCRC-approved rates for services provided at an outpatient clinic located off the grounds of the hospital. The federal Health Care Financing Administration determined at that time that it would only pay for services at the freestanding ambulatory center rates.
House Bill 242 (passed) eliminates the sunset date on the Health Services Cost Review Commission's special fund and increases the limit on the HSCRC's user fees from $3 million to $3.5 million. This bill will permit HSCRC to continue to operate its special fund. If the special fund were to sunset, the money collected by the HSCRC would be deposited into the general fund. The fiscal 2000 budget includes $2.9 million in special fund expenditures and revenues for the HSCRC and $36.9 million for a hospital uncompensated care pool fund that is separate from the HSCRC's operating expenditures.
Senate Bill 499/House Bill 277 (both failed) would have required the Health Resources Planning Commission (HRPC) to initiate an application process for a new open heart surgical program in the health planning area encompassing Montgomery County, Prince George's County, or Southern Maryland. HRPC's need-based methodology for open heart surgery programs would not have applied to the creation of this program. However, all other provisions of the certificate of need application process, including the impact on other providers of the same service, would have applied.
Nursing Homes
Current law leaves Medicaid reimbursement policy to the discretion of the Department of Health and Mental Hygiene (DHMH). Medicaid pays for 67% of nursing home care in Maryland. Of the $35 million in cost containment imposed on nursing homes since 1993, $16.5 million has been restored. In 1994, DHMH found that nursing homes were providing more hours than they were being paid for under the existing reimbursement formula. DHMH can adjust the formula by regulation to reflect the additional hours; to do so, however, would have cost approximately $20 million in fiscal year 1998. Nursing homes that serve relatively few private pay patients have particular difficulty accommodating Medicaid cost containment.
Chapter 724 of 1998 required the DHMH to study the feasibility of altering the payment parameters, structure, and target occupancy percentage that is currently used for Medicaid reimbursement for nursing facilities. The cost of implementing the report's recommendations directly affecting the formula would be $23.2 million. No funding is included in the fiscal 2000 budget to implement the report's recommendations. However, $9 million is restored to the existing nursing home formula to eradicate most of the continuing cost containment actions from the early 1990s.
Senate Bill 740/House Bill 791 (both passed) include three provisions relating to nursing homes: (1) a reduction of payments to nursing homes for reserved beds; (2) the establishment of a task force to study the quality of care in nursing homes; and (3) a requirement for the Health Care Access and Cost Commission (HCACC) to produce a nursing home report card.
The bills reduce the Medicaid per diem rate for reserved nursing facility beds when the patient is absent from the nursing facility by excluding the cost of nursing services in the rate calculation. The current Medicaid nursing home reimbursement formula pays the same per diem rate for nursing home residents regardless of whether the individual is physically present in the nursing facility, subject to certain limitations. The bills require that general fund savings from reducing the Medicaid per diem rate be used to increase the nursing services cost center of the Medicaid nursing home reimbursement formula.
Senate Bill 740/House Bill 791 establish a 13-member Task Force on Quality of Care in Nursing Facilities to study the quality of care in Maryland nursing homes, including current quality of care standards, staffing patterns, and procedures for nursing home inspections. The Task Force must report its findings and recommendations to the General Assembly by December 1, 1999, and sunsets on May 31, 2000.
The bills also require HCACC, in consultation with DHMH and the Department of Aging, to develop a system to comparatively evaluate nursing facility quality of care and performance on an objective basis by July 1, 2001, and to publish an annual summary of the comparative evaluation.
Under Senate Bill 740/House Bill 791, Medicaid expenditures for reserved nursing home beds would decrease by $5.0 million ($2.5 million general funds, $2.5 million federal funds) in fiscal year 2000. Medicaid expenditures for the nursing home reimbursement formula would increase by an equal amount.
Assisted Living
Chapter 147 of 1996 consolidated various types of community-based senior housing under the category "assisted living" and designated the Department of Health and Mental Hygiene (DHMH) as the lead agency for regulating assisted living programs. Assisted living is a category of care and housing for the elderly and individuals with disabilities that provides housing and supportive services, supervision, and health-related services to meet the needs of individuals who are no longer able to perform the activities of daily living.
Assisted living regulations to implement Chapter 147 went into effect January 1, 1999. There are approximately 4,000 assisted living programs, of which approximately 2,800 have 15 or fewer residents. Concerns exist as to whether the regulations will cause small providers to either leave the industry or increase their resident fees. In response to these concerns, Senate Bill 187/House Bill 296 (both passed) extend, from July 1, 1999, to July 1, 2000, the date before which DHMH is prohibited from imposing sanctions on small assisted living programs, unless a resident's physical or emotional health has been harmed or is jeopardized.
Level 3 is the highest level of care for which an assisted living facility may be licensed. A "level of care 3 plus waiver" is a resident-specific waiver granted by DHMH under the assisted living regulations for an individual who has a condition that would ordinarily require nursing home level of care but who desires to age in place. DHMH may grant resident-specific waivers for up to 20% of the bed capacity of an assisted living program or 20 beds, whichever is less. Senate Bill 721 (passed) requires DHMH to submit a report to the Governor and General Assembly each year on the number and duration of "level of care 3 plus waivers" granted in the preceding year. The bill's provisions sunset on September 30, 2004.
To reduce the administrative burden on DHMH in licensing assisted living programs, House Bill 69 (passed) alters the term of licensure for an assisted living program from one year to two years and requires at least one unannounced inspection of assisted living programs every year.
Continuing Care Retirement Communities
Continuing care retirement communities (CCRCs) offer a continuum of care within the same campus to a senior citizen who wishes to age in place, including independent living units, assisted living units, and nursing home beds.
Senate Bill 145/House Bill 359 (both passed) seek to reduce the administrative burden placed on continuing care retirement communities by the assisted living regulations that went into effect January 1, 1999. The bills exempt an assisted living program in a continuing care retirement community from having to execute an agreement or disclosure statement that is separate from the CCRC resident agreement and disclosure statement. However, if a CCRC decides not to execute a separate resident agreement and disclosure statement for assisted living, it will be required to include in its resident agreement and disclosure statement certain items that pertain to assisted living.
As the need for additional nursing home beds has declined statewide, the certificate of need (CON) exemption process has been the predominant route by which CCRCs have added nursing home beds. Eleven of the 29 CCRCs in Maryland have CON-exempt nursing home beds.
Current law allows CCRCs to have CON-exempt nursing home beds if the beds are for the exclusive use of community residents. A CCRC is prohibited from allowing the public direct admissions to its nursing home beds. Therefore, if a husband and wife sign up for a CCRC and the wife becomes ill, she cannot move directly into the nursing home while her husband occupies the independent living unit. Senate Bill 159/House Bill 360 (both passed) provide that a continuing care community does not lose its exemption from CON requirements when it admits an individual directly to a nursing facility within the community if the admittee's spouse, relative, or significant other is admitted at the same time to an independent living or assisted living unit within the community.
Adult Dependent Care Programs
Adult dependent care programs include adult day care facilities, assisted living facilities, group homes, home health agencies, congregate housing facilities, residential service agencies, alternative living units, hospice facilities, and nursing homes. The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services found in a September 1998 report that states use a patchwork of measures to identify individuals who pose a possible threat to residents of long-term care facilities. The Inspector General's report recommends that the Health Care Financing Administration consider establishing federal requirements and criteria for performing criminal background checks and assisting in the development of a national abuse registry. Under current Maryland law, only a State criminal history records check or private agency background check is required. Adult dependent care programs appear to prefer the private agency checks, which are more comprehensive and timely than the State or federal criminal history records checks.
Senate Bill 567 (failed) would have required a "private agency", if requested by an adult dependent care program, to conduct a background check for a prospective employee check in each state in which there was reason to believe that the prospective employee worked or resided during the past seven years. It would have imposed certain requirements, including licensure and insurance, on such a private agency. House Bill 18 (failed) would have required adult dependent care programs to apply and pay for national and State criminal history records checks for prospective employees.
Home Health/Hospice
Senate Bill 773/House Bill 1153 (both passed) repeal the September 30, 1999 termination date for current law providing that a home health agency accredited by an organization approved by the Department of Health and Mental Hygiene (DHMH) is deemed to meet State licensure standards. Accredited home health agencies do not require State licensure inspections. However, DHMH is authorized to investigate a complaint or follow up on a problem indicated by the accreditation agency's report.
The Advisory Committee to the Secretary of Health and Mental Hygiene on Home-Based Health Care Services (Committee) was established by Chapter 133 of 1998 and was charged with studying the current statutory framework for regulating the home health industry. The Committee found a lack of consistent regulation for providers of home-based health care services, a lack of a consumer complaint process, and a lack of training standards and work standards for home-based health care services staff. Drafted in response to the Committee's recommendations, Senate Bill 359/House Bill 484 (both failed) would have repealed current law regulating home health agencies, residential service agencies, and nursing staff agencies and would have created statutory authority for a new consolidated entity, called a "community-based heath agency," to be regulated by DHMH.
A certificate of need (CON) is the primary method for implementing the State Health Plan and is generally required for capital expenditures, additions, or modifications to existing facilities or services, and for new services. The basis for approval of a CON is need, as determined in the State Health Plan. House Bill 993 (failed) would have repealed the requirement that a CON is needed for a home health agency or any health care service that a home health agency provides. House Bill 717 (failed) would have exempted home-based hospice care from CON requirements.
MENTAL HEALTH/DEVELOPMENTAL DISABILITIES
The Community Services Reimbursement Rate Commission (CSRRC) was created by Chapter 593 of 1996 out of frustration with the absence of cost of living adjustments in the Department of Health and Mental Hygiene's budget for developmental disabilities and mental health community services providers. Low salaries were impeding the providers' ability to attract and retain qualified staff. Senate Bill 448 (passed) extends the CSRRC's termination date from September 30, 1999 to September 30, 2002 and alters the factors that it must assess regarding rate setting for community services providers.
HEALTH MAINTENANCE ORGANIZATIONS
QUALITY OF CARE
HMO Quality Assurance Unit - Quality Assurance Medical Director
Recognizing ongoing consumer concerns about the quality of care provided by Health Maintenance Organizations (HMOs), the General Assembly introduced House Bill 1210 (passed) which establishes an HMO Quality Assurance Unit within the Department of Health and Mental Hygiene (DHMH). The Quality Assurance Unit is administered by a medical director, who has broad authority to review and determine whether an HMO meets quality standards established by law and to make recommendations to the Secretary for any required corrective changes. If an HMO does not meet these quality standards, the Secretary may issue an order requiring the HMO to cease inappropriate conduct or provide a service that has been improperly denied. As an alternative, the Secretary may impose a fine of up to $125,000 or apply to any court for legal equitable relief.
The legislation requires the HMO Quality Assurance Unit to enforce certain quality of care requirements established in law or by regulation and to investigate quality of care complaints referred by the Maryland Insurance Administration.
Formulary Development Process - Accreditation Status
The HMO report card is an annual consumer guide on the quality of Maryland HMOs. The report card comparatively measures such quality indicators as access to care, enrollee satisfaction, and the provision of preventive health care services. The Health Care Access and Cost Commission (HCACC) distributes the report card annually to HMOs, consumers, employers, health care providers, and government. House Bill 980 (passed) requires the HCACC to include in the report card a summary of the drug formulary accreditation standards developed by the National Committee for Quality Assurance (NCQA) and to indicate whether the formulary development process of each HMO evaluated complies with the NCQA accreditation standards.
MANAGED CARE LIABILITY
With at least 160 million Americans enrolled in managed care organizations that review and approve utilization of health care services, many states have begun to consider the liability of these organizations when an organization denies coverage for a particular treatment procedure and a member suffers ill effects as a result of that health care coverage decision.
Health Care Treatment Decisions - Liability
Senate Bill 261 (failed) would have established a cause of action against a health insurer, nonprofit health service plan, HMO, or dental plan organization (carrier) that does not exercise ordinary care when making health care treatment decisions. Senate Bill 261 was intended to provide a clear statutory basis on which a person may sue a carrier. Similar legislation was introduced during the 1998 Session as Senate Bill 84. For further discussion of Senate Bill 261, see Part F - Civil Actions and Procedures of The 90 Day Report.
Practice of Medicine/Practice of Dentistry
Senate Bill 594/House Bill 243 (both failed) would have included within the definition of "the practice of medicine" the making of a determination that a health care service is not medically necessary or medically appropriate. Similarly, Senate Bill 595/House Bill 594 (both failed) would have included within the definition of "the practice of dentistry" the making of a determination that a dental service is not medically or dentally necessary or medically or dentally appropriate. Generally, HMOs and other carriers assert that a determination of medical necessity is a coverage issue and therefore does not impact delivery of health care services by a provider. Under the bills, if an HMO or managed dental plan medical director reviewed an enrollee's proposed course of treatment and deemed it to be not medically necessary the medical director may have been liable for medical malpractice if the enrollee suffered harm as a result of the denial. Similar legislation was introduced during the 1998 Session as Senate Bill 654.
CONTINUITY OF PATIENT CARE ACT
Senate Bill 475/House Bill 576 (both passed) require HMOs to reimburse an urgent care facility physician, oral surgeon, periodontist, or podiatrist for providing any medically necessary follow-up care related to the condition for which a covered emergency surgical procedure was performed. The follow-up care must be medically necessary, directly related to the condition for which the procedure was performed, and provided in consultation with the member's primary care physician. Senate Bill 475/House Bill 576 also prohibit an HMO from imposing any copayment or other cost-sharing requirement on the member that exceeds what the member is required to pay for services rendered by a physician, oral surgeon, periodontist, or podiatrist who is a member of the HMO's provider panel.
REIMBURSEMENT FOR MEDICAL SCREENING, ASSESSMENT, AND STABILIZATION SERVICES
Senate Bill 629/House Bill 627 (both passed) repeal the sunset provision on the requirement that HMOs pay hospital and emergency providers for the cost of medical screenings performed to meet the requirements of the federal Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA, commonly known as the antidumping law, requires hospital emergency facilities to assess and stabilize all patients seeking treatment as a condition of receipt of Medicare reimbursements. The law prohibits an emergency facility from contacting an HMO to request authorization for treating an enrollee or from transferring an enrollee to an HMO urgent care facility or physician's office without first stabilizing the patient's condition.
PRIVATE CONTRACTS FOR HEALTH CARE SERVICES
Senate Bill 520/House Bill 676 (both failed) would have authorized a health care provider who is not under contract with an HMO to collect or attempt to collect payment from an enrollee for a covered service provided to the enrollee. In addition, the legislation would have provided that an enrollee can privately contract with a health care provider who is not under contract with the HMO. House Bill 676, as amended, limited the circumstances under which such private contracting would be allowed. Although both Senate Bill 520/House Bill 676 failed, House Bill 995 (passed) requires the Maryland Insurance Administration to study payments to noncontracting providers.
A report issued by the Department of Legislative Services in August 1998 and a report issued in July 1998 by Families USA entitled "Hit & Miss: State Managed Care Laws" indicate that Maryland compares favorably to other states and the federal government in adopting laws that protect patients' rights under managed care systems. Among other things, these reports indicate that Maryland has already taken important steps to ensure access to emergency and nonemergency care, protect the provider-patient relationship, assure quality of care, establish external complaint and internal grievance processes, mandate important benefits, and protect confidentiality of patient information.
During the 1999 Session, the General Assembly passed House Bill 182 (passed), which establishes additional protections for patients in a managed care environment. To facilitate a patient's access to and use of available health care options, the bill establishes the Maryland Insurance Administration (MIA) as the "single point of entry" for consumers who seek to obtain information relating to health insurance. The bill also provides patients, under certain circumstances, the right to direct access to specialists, to obtain prescription drugs that are not included in a carrier's formulary, and to a home visit following certain surgeries.
House Bill 182 requires carriers that do not allow direct access to specialists to establish and implement procedures by which a member, under certain circumstances, may: (1) receive a standing referral to a specialist; and (2) obtain a referral to a specialist who is not part of the carrier's provider panel. A carrier is required to authorize a standing referral to a specialist if: (1) the primary care physician determines, in consultation with the specialist, that the member needs continuing care from the specialist; (2) the member has a condition or disease that is life threatening, degenerative, chronic, or disabling and requires specialized medical care; and (3) the specialist has expertise in treating the disease or condition and is a part of the carrier's provider panel. The bill requires that the standing referral be made in accordance with a written treatment plan developed by the primary care physician, specialist, and member.
To address access to out of network specialist providers, House Bill 182 requires a carrier to allow a member to obtain a referral to a specialist who is not a part of the carrier's provider panel if: (1) the member is diagnosed with a condition or disease that requires specialized care; (2) the carrier does not have in its provider panel a specialist with the professional training and expertise to treat the disease or condition; and (3) the specialist agrees to accept the same reimbursement as would be provided to a specialist who is a member of the carrier's provider panel.
A carrier that limits its coverage of prescription drugs or devices to those in a formulary is required by House Bill 182 to establish and implement a procedure by which a member may receive a prescription drug or device that is not in the carrier's formulary if, in the judgment of the authorized prescriber: (1) there is no equivalent prescription drug or device in the carrier's formulary; or (2) an equivalent prescription drug or device in the carrier's formulary has been ineffective or has caused or is likely to cause an adverse reaction or other harm to the member. A carrier's decision not to provide access to or coverage of a prescription drug or device as required by House Bill 182 on the grounds that the drug or device is not medically necessary, appropriate, or efficient constitutes an adverse decision under the current law governing external appeals and internal grievances.
Included in House Bill 182 is a new mandated benefit for home visits after a mastectomy or surgical removal of a testicle. Specifically, the bill mandates the following coverage for a patient who receives less than 48 hours of inpatient hospitalization following a mastectomy or the surgical removal of a testicle or who undergoes a mastectomy or the surgical removal of a testicle on an outpatient basis: (1) one home visit within 24 hours after discharge from the hospital or outpatient health care facility; and (2) an additional home visit if prescribed by the attending physician. These provisions, however, sunset on September 30, 2003.
COLLECTION, USE, AND DISCLOSURE OF GENETIC INFORMATION
In response to increasing concerns about the ability of employers to use genetic information as the basis for refusing to hire, firing, or otherwise discriminating against an individual, the General Assembly passed legislation this year that expands the scope of current provisions relating to the use of genetic tests. Senate Bill 774 (Ch. 50)/House Bill 862 (Ch. 51) expand a provision of current law that prohibits an insurer, nonprofit health service plan, or health maintenance organization (HMO) (carrier) from using a genetic test or the results of a genetic test to reject, deny, limit, cancel, refuse to renew, increase the rates of, affect the terms and conditions of, or otherwise affect a health insurance policy or contract to make this provision applicable to "genetic information." The Acts expand a provision of current law that prohibits a carrier from requesting or requiring a genetic test for the purpose of determining whether or not to issue or renew health benefits coverage to make this provision applicable to "genetic information."
Under Senate Bill 774/House Bill 862, "genetic information" means information: (1) about chromosomes, genes, gene products, or inherited characteristics that may derive from an individual family member; (2) obtained for diagnostic and therapeutic purposes; and (3) obtained at a time when the individual to whom the information relates is asymptomatic for the disease.
Senate Bill 774/House Bill 862 also modify current disclosure requirements to prohibit the release of identifiable genetic information or the results of a genetic test to any person who is not an employee of the health insurer or a participating health care provider without the written authorization of the individual from whom the test results or genetic information was obtained. In recognition of the fact that many large employers currently serve as their own health insurers through self-funded systems, Senate Bill 774/House Bill 862 specify that disclosure to employees of the insurer may be made only for the purpose of providing medical care to patients or conducting research that has been approved by an institutional review board.
MARYLAND INSURANCE ADMINISTRATION - ENFORCEMENT
Unfair Claims Settlement Practices
In passing House Bill 139 (Ch. 71), the General Assembly demonstrated its continuing desire to provide agencies with the tools they need to properly regulate insurers, nonprofit health services plans, and HMOs. House Bill 139 expands the types of conduct that constitute unfair claims settlement practices by insurers and nonprofit health service plans under current law to include, as a general business practice, the refusal to pay a claim for an arbitrary or capricious reason. House Bill 139 also gives the Maryland Insurance Administration (MIA) authority to impose new penalties for violations relating to unlawful, misleading, deceptive, or fraudulent conduct of HMOs.
Under current law, if an insurer or nonprofit health service plan engages in an unfair claims settlement practice, the MIA may: (1) impose a penalty of not less than $100 and not more than $125,000; and (2) require the insurer to pay restitution to any person who has sustained financial injury as a result of the practice. House Bill 139 authorizes the MIA to impose these same sanctions on an HMO that engages in specific types of unlawful, misleading, deceptive, or fraudulent conduct.
Standard Contract and Policy Provisions
Under current law, different types of insurance (e.g., group, blanket, and individual) are subject to different statutory requirements regarding standard provisions that must be included in contracts and policies. In order to bring uniformity and consistency to this area of the law, House Bill 43 (passed) repeals the inconsistent provisions of current law and substitutes a requirement that the Insurance Commissioner adopt regulations that establish standard language and format for all contracts and policies issued by insurers, nonprofit health service plans, and HMOs.
Stop-Loss Insurance Policies
In American Medical Security, Inc., et al. v. Bartlett, 111 F.3d 358 (4th Cir. 1997), cert. denied 118 S.Ct. 2340 (1998), the United States Court of Appeals for the Fourth Circuit considered the issue of whether the federal Employee Retirement Income Security Act of 1974 (ERISA) preempts the Maryland Insurance Administration (MIA) from establishing by regulation the minimum attachment point for stop-loss insurance policies issued to self-funded employer-based health plans covered by ERISA. Stop-loss insurance provides coverage to self-funded plans above a certain level of risk.
The 4th Circuit Court acknowledged the legitimate concern of the State regulator over the sale of such policies, but found that Congress, through a change in ERISA, must remedy the problem. In June 1998, the Supreme Court declined to review the 4th Circuit decision.
In an effort to clarify the issue, the General Assembly passed House Bill 1086 (passed). The bill prohibits an insurer from issuing, delivering, or offering in Maryland a policy or contract of stop-loss insurance if the policy or contract has: (1) a specific attachment point of less than $10,000; or (2) an aggregate attachment point of less than 115% of expected claims. The bill provides that its requirements are imposed only on insurers and that any stop-loss policy must not be treated as a direct policy of health insurance.
PROVIDER REIMBURSEMENT ISSUES
Private Review Agents - Retroactive Adverse Decisions
Under current law, private review agents are authorized to retrospectively deny preauthorized or approved services delivered to a patient under certain circumstances. Senate Bill 350/House Bill 345 (both passed) narrow the circumstances under which a private review agent may retroactively deny preauthorized or approved services. Specifically, Senate Bill 350/House Bill 345 repeal provisions of current law that allow such retroactive denials if: (1) the patient, on the date the services were rendered, was not insured; or (2) the services were not covered in whole or in part under the policy or contract. Senate Bill 350/House Bill 345 also require all group health insurance policies to include a provision that requires the employer, labor union, or association to continue to pay the premium for an employee, member, or dependent until notice of termination of coverage is received by the insurer.
Retroactive Denial of Reimbursement - Improper Coding
Current law imposes time limitations on the retroactive denial of reimbursement to a health care provider. With certain exceptions, an insurer, nonprofit health service plan, HMO, or dental plan organization (carrier) may retroactively deny reimbursement of a claim only if the denial is made: (1) within 18 months after payment of the claim, if the claim is for a service that is subject to coordination of benefits with another carrier, the State Medical Assistance Program, or the federal Medicare program; or (2) within six months after payment of the claim, for all other claims. These time limitations currently do not apply if a provider submits information that was fraudulent or improperly coded. The term "improperly coded," however, is not defined in current law.
Senate Bill 250/House Bill 346 (both passed) specify that information is improperly coded if it: (1) uses codes that do not conform to the coding guidelines used by the carrier on the date that the service is provided; or (2) does not otherwise conform to the contractual obligations of the provider on the date that the service is provided. Senate Bill 250/House Bill 346 also provide that the "improper coding" exception to the current time limitations on retroactive denials is applicable only if the carrier gives the provider sufficient information regarding the coding guidelines used by the carrier at least 30 days before the date of the service.
Fee Schedules, Coding Guidelines, Bonuses, and Incentives
Under current law, health insurers, nonprofit health service plans, HMOs, and dental plan organizations (carriers) are authorized to provide bonuses or other incentive-based compensation to health care practitioners if the bonuses or other incentive-based compensation comply with statutory standards relating to quality of care and do not deter the delivery of medically appropriate care to an enrollee. House Bill 572 (passed) requires the bonus or other incentive-based compensation to "promote" the delivery of medically appropriate care to an enrollee. The bill prohibits a bonus or other incentive-based compensation for services, other than preventive health care services, based on the cost or number of medical services provided, proposed, or recommended by the health care practitioner without reference to the medical appropriateness or necessity of the services.
House Bill 572 also requires that a carrier provide a health care practitioner with: (1) a schedule of applicable fees for up to the twenty most common services billed by a health care practitioner in that speciality; (2) a description of the coding guidelines used by the carrier that are applicable to the services billed by a health care practitioner in that specialty; and (3) the information about the practitioner and the methodology used by the carrier to determine whether to increase or reduce the level of reimbursement to the practitioner or provide a bonus or other incentive-based compensation.
Payment of Claims
House Bill 639 (passed) eliminates inconsistencies in current law regarding a carrier's payment of claims and interest on late payments. Specifically, the bill makes provisions of current law that require insurers and nonprofit health service plans to pay claims within certain periods and to pay certain interest on late payments applicable to HMOs and managed care organizations (MCOs) that participate in the Maryland Medical Assistance Program (Medicaid).
Under House Bill 639, a health care provider must submit a claim for reimbursement to an insurer, nonprofit health service plan, HMO, or Medicaid MCO (carrier) within six months from the date of a covered service. Within 30 days after receipt of a claim for reimbursement, the carrier is required to pay the claim or send a notice of receipt and status of the claim that states that: (1) the carrier refuses to reimburse all or part of the claim and the reason for the refusal; or (2) additional information is necessary to determine if all or part of the claim will be reimbursed. If the carrier requests additional information, it must reimburse a provider for a covered service within 30 days after receipt of all reasonable and necessary documentation.
Reimbursement for the Costs of Oncology Drugs
The General Assembly passed legislation during the 1998 Session that allows an insurer, nonprofit health service plan, HMO, or dental plan organization (carrier) to reimburse a health care practitioner for less than the cost of an oncology drug used by the practitioner in treating a patient in the practitioner's office if the carrier provides an alternative mechanism or program for the practitioner to use to obtain the oncology drug. House Bill 280 (passed) repeals this provision.
MANDATED BENEFITS AND COVERAGES
Mandated Health Insurance Services - Cost Determinations
Currently, Maryland has 37 mandated benefits or offerings for services and provider reimbursement. Twenty-five of these require an insurer, nonprofit health service plan, or HMO to provide coverage for or offer coverage for a particular service or treatment; twelve require an insurer, nonprofit health service plan, or HMO to provide reimbursement for or offer to provide reimbursement for expenses arising from services rendered by specified health care professionals or facilities (e.g., chiropractors, optometrists, emergency rooms). Due to different methods of aggregation and varying definitions of other requirements, it is difficult to count the number of mandates that require an insurer, nonprofit health service plan, or HMO to provide certain coverage to dependents or the conversion/continuation of benefits.
In December 1998, the Health Care Access and Cost Commission (HCACC) submitted the "Mandated Health Insurance Services Evaluation" to the General Assembly. The report included an evaluation of the social, medical, and financial impacts of proposed mandated benefits and the cost of existing mandated benefits as a percentage of Maryland's average wage and health benefits premiums. While the report indicates the cost of all current mandates is approximately 15.5% of premiums, the General Assembly continues to be cognizant that mandated benefits may have an inflationary effect on premiums. Senate Bill 625/House Bill 283 (both passed) require the HCACC to: (1) update the full cost of all existing mandated health benefits; (2) annually evaluate the social, medical, and financial impacts of proposed mandates; and (3) do a full evaluation of all existing mandates if their total cost reaches 2.2% of Maryland's average wage. The cost of Maryland's 30 mandated benefits currently averages 1.9% of Maryland's average wage. The HCACC does not anticipate reaching the 2.2% average wage cap in FY 2000.
Access to the 911 Emergency System
Senate Bill 618/House Bill 767 (both passed) prohibit carriers from establishing or promoting an emergency medical transportation system that competes with Maryland's 911 system. Carriers may still use an alternate transportation system, however, for nonemergency situations. Carriers cannot require enrollees to obtain prior authorization before accessing the 911 system for an emergency medical condition.
Annual Chlamydia Screening Test
House Bill 46 (Ch. 57) requires carriers to provide coverage for an annual chlamydia screening test for men and women who have certain risk factors. Currently, approximately 70% of all health care plans include coverage for a chlamydia screening exam for either at-risk or symptomatic persons. House Bill 46 standardizes the frequency of and circumstances under which an exam may be performed.
Medical Clinical Trials
Current law requires carriers to cover costs associated with Phases I, II, III, and IV clinical trials for cancer, and Phases II, III, and IV clinical trials for other life-threatening conditions. Currently, carriers have the option of covering Phase I clinical trials for life-threatening conditions on a case-by-case basis. Senate Bill 101/House Bill 109 (both passed) require coverage for all clinical trials involving life-threatening conditions.
Coverage for a Prosthesis
Senate Bill 181/House Bill 168 (both passed) require carriers to provide coverage for a prosthesis for individuals who have undergone a mastectomy and have not had breast reconstruction. Current federal law requires prosthesis coverage for a patient who elects to undergo breast reconstruction surgery. Senate Bill 181/House Bill 168 address the present insurance coverage gap that exists for a woman who may not elect to undergo breast reconstruction surgery following a mastectomy but who wishes to receive a breast prosthesis.
Universal Newborn Hearing Screening
Senate Bill 624/House Bill 884 (both passed) expand the Program for Hearing-Impaired Infants within the Department of Health and Mental Hygiene (DHMH) to include universal hearing screening for all newborns and requires carriers to provide coverage for the hearing loss screenings. For further discussion of Senate Bill 624/House Bill 884, see Part J - Public Health - Generally of The 90 Day Report.
Home Visits After Mastectomy or Removal of Testicle
As discussed above in connection with the Patients' Bill of Rights, the General Assembly created a new mandated benefit in House Bill 182 (passed) for home visits after a mastectomy or surgical removal of a testicle.
Extension of Benefits
Senate Bill 67 (passed) requires carriers to extend insurance benefits in certain situations to individuals whose insurance coverage terminates for reasons other than: (1) the individual's failure to pay required premiums; (2) fraud; or (3) coverage is provided by a succeeding health benefit plan. Carriers cannot charge a premium during an extension period. Senate Bill 67 codifies current practice within the Maryland Insurance Administration (MIA), which requires carriers to extend benefits under most of the circumstances enumerated in Senate Bill 67. The only deviation from current practice is the bill's requirement that HMOs extend benefits up to 12 months. The MIA currently requires HMOs to extend benefits up to 90 days.
MANAGED BEHAVIORAL HEALTH CARE ORGANIZATIONS
Current law requires a carrier to disclose in its enrollment sales materials, in layperson's terms, the reimbursement methodologies the carrier uses to reimburse physicians and to disclose, in the form of a pie chart or graph, the distribution of each $100 the carrier receives in premium dollars for the preceding calendar year.
Senate Bill 585/House Bill 931 (both passed) require carriers to file a report on the mental health expense ratio of behavioral health care services to the Maryland Insurance Administration. The health expense ratio is the percentage of premium revenues spent on mental health care services. A carrier must also distribute to its members at the time of enrollment an explanation of: (1) the specific behavioral health care services covered and excluded; (2) the member's responsibilities for obtaining behavioral health care services; (3) the reimbursement methodology that the carrier and managed behavioral health care organization use to reimburse providers; and (4) the procedure that a member must use when attempting to obtain behavioral health care services outside the carrier's provider network. Senate Bill 585/House Bill 931 also create a task force to develop quality measures for behavioral health care services to enrollees of managed behavioral health care organizations. The task force must report its findings to the General Assembly by December 15, 1999.
MISCELLANEOUS ISSUES
Task Force to Study Non-Group Health Insurance Market
House Bill 43 (passed) creates a Task Force to Study the Non-Group Health Insurance Market. The Task Force is required to review and study the characteristics of the non-group market, including: (1) the non-group market products available in the State; (2) the demographics of those insured in the non-group market; (3) the affordability of and pricing considerations in the non-group market; and (4) trends in premium costs for non-group products. The Task Force is required to recommend whether changes should be made to the State laws governing the non-group market in a preliminary report by December 15, 1999. A final report is due December 15, 2000.
Assignment, Transfer, or Subcontracting of Provider Contracts
Under current law, an insurer, nonprofit health service plan, HMO, or dental plan organization (carrier) is prohibited from assigning, transferring, or subcontracting a health care provider's contract to an insurer that offers statutorily mandated personal injury protection under a motor vehicle liability insurance policy (PIP coverage) without first obtaining the provider's written consent. House Bill 1216 (passed) clarifies that a carrier is also prohibited from terminating, limiting, or otherwise impairing the contract or employment of a provider with the carrier on the basis that the provider refused to agree to the assignment, transfer, or subcontract of the provider's contract to an insurer that offers PIP coverage.
Uniform Credentialing Form
Senate Bill 641 (passed) requires insurers, nonprofit health service plans, HMOs, and dental plan organizations (carriers) and their credentialing intermediaries to accept a uniform credentialing form established by the Insurance Commissioner as the sole application for a health care provider to become credentialed or recredentialed for a provider panel. The bill also requires the carrier or credentialing intermediary to make the uniform credentialing form available to any provider who is to be credentialed or recredentialed. The Insurance Commissioner is authorized under Senate Bill 641 to impose a penalty of up to $500 on a carrier or credentialing intermediary that violates these requirements.
Health Benefit Plans - Small Employers
Under current law, a carrier that offers a health benefit plan to small employers is required to establish a community rate for the plan using a rating methodology that is based on the experience of all risks covered by the plan without regard to health status or occupation. Carriers are currently authorized to adjust the community rate for age and geography within the following geographic regions of the State: the Baltimore metropolitan area, the District of Columbia metropolitan area, Western Maryland, and Eastern and Southern Maryland. Based on these authorized adjustments, a carrier may charge a rate that is 33% above or below the community rate. House Bill 918 (passed) allows a carrier, based on the same authorized adjustments, to charge a rate that is 40% above or below the community rate.
Health Care Decisions - External Complaints and Internal Grievances
During the 1998 Session, the General Assembly passed legislation that required health insurers, nonprofit health service plans, dental plan organizations, and HMOs (carriers) to establish internal grievance procedures for adverse decisions relating to their enrollees. The 1998 legislation also authorized an enrollee to file a complaint with the Insurance Commissioner after completing the internal grievance process and authorized the Insurance Commissioner to collect a health care regulatory assessment from carriers to cover the cost of the implementing the complaint process.
Senate Bill 699/House Bill 1023 (both passed) expand the types of carriers that are exempt from the current requirements relating to appeals and grievances and the health care regulatory assessment to include a carrier that offers: (1) accidental travel or accidental death and dismemberment insurance; (2) credit health insurance; (3) any insurance, medical policy, or certificate for which payment of benefits is conditioned on a determination of medical necessity made solely by the treating health care provider not acting on behalf of the carrier; and (4) any other insurance, medical policy, or certificate for which payment of benefits is not conditioned on a determination of medical necessity.
Senate Bill 699/House Bill 1023 also establish that the current complaint and grievance procedures apply to individuals who reside or work in Maryland even if the health benefit plan is delivered or issued in another state when the other state does not have a comparable process for reviewing external complaints.
State Regulation of Self-Funded Employer-Based Health Plans
The federal Employee Retirement Income Security Act of 1974 (ERISA) prohibits states from regulating self-funded employer-based heath plans. In Maryland, these types of plans currently represent approximately 40% of employer-based health plans. There is growing concern, however, that consumers who are enrolled in these plans are not receiving adequate protection due to ERISA preemption. In recognition of this concern, the General Assembly passed Senate Joint Resolution 7/House Joint Resolution 8 (both passed), requesting that the United States Congress amend ERISA to authorize states to monitor and regulate self-funded employer-based health plans.
Mental Hygiene Administration
Out-Year-Cost of Fiscal 2000 Program Changes
($ in Thousands)