Part J
Health
Tobacco Settlement
Cigarette Restitution Fund
The Master Settlement Agreement is a watershed in the long history of tobacco litigation. Under this unprecedented agreement, the settling manufacturers will make regular payments to 46 states, 5 territories, and the District of Columbia as well as conform to a plethora of restrictions on marketing to youth and the general public. The fiscal 2001 budget bill contains the first appropriation of settlement payments from the Cigarette Restitution Fund, with $102.5 million allocated for fiscal 2000 deficiencies and $163.75 million for fiscal 2001 programs. For more detail, see Part A - Budget and State Aid of this 90 Day Report.
To establish parameters for tobacco and cancer control programs supported by cigarette restitution funds, Senate Bill 896/House Bill 1425 (both passed) create the Tobacco Use Prevention and Cessation Program and the Cancer Prevention, Education, Screening, and Treatment Program under the Department of Health and Mental Hygiene (DHMH). Funding for the programs must be specified in the annual budget bill. In the fiscal 2001 budget, a total of $18.1 million is earmarked for the Tobacco Use Prevention and Cessation Program and $30.8 million for the Cancer Prevention, Education, Screening, and Treatment Program. With the exception of some planning and start-up activities, no funds for either program may be expended until baseline studies are completed. At the end of the fiscal year, any money that is reverted to the Cigarette Restitution Fund should be appropriated for the same program in the following fiscal year.
Tobacco Use Prevention and Cessation Program
The purpose of the Tobacco Use Prevention and Cessation Program is to reduce tobacco use among youth, targeted minorities, and the general population. The program has five components: Administrative, Surveillance and Evaluation, Statewide Public Health, Counter-Marketing, and Local Public Health. While Senate Bill 896/House Bill 1425 do not allocate funding among the components, the legislation mandates that the annual budget bill specify the funding for each component.
In the tobacco program, the Administrative Component includes all departmental activities related to administering the program. Unless otherwise specified in the Budget Bill, funding for the Administrative Component may not exceed five percent of the total funding for other components. Other entities that receive funds from the department may use a maximum of seven percent of the award for administrative expenses.
To implement and monitor the success of the tobacco program, the department will conduct a baseline survey of tobacco use, annual follow-up surveys of tobacco use, and program evaluations under the Surveillance and Evaluation Component. To facilitate coordination of all activities of the program, DHMH shall conduct activities under the Statewide Public Health Program.
Under the Local Public Health Component of the tobacco program, DHMH will distribute funds to community health coalitions through the local health departments for anti-tobacco use programs that are consistent with the recommendations of the Centers for Disease Control and the Task Force to End Smoking. To receive funds, a coalition must submit a comprehensive plan. The funding formula is based on the number of individuals and minors who use tobacco products.
Cancer Prevention, Education, Screening, and Treatment Program
The purpose of the Cancer Prevention, Education, Screening, and Treatment Program is to reduce the morbidity and mortality from cancer in targeted minority populations and the general population. The program has five components: Administrative, Surveillance and Evaluation, Statewide Public Health, Local Public Health, and Academic Health Center. While Senate Bill 896/House Bill 1425 do not allocate funding among the components, the legislation mandates that the annual budget bill specify the funding for each component.
The Administrative, Surveillance and Evaluation, and Statewide Public Health Components are similar to the tobacco program. The Local Public Health and Statewide Academic Health Center Components are structured differently in the cancer program.
Under the Local Public Health Component of the cancer program, DHMH will award funds to community health coalitions through the local health departments based on a comprehensive plan. The coalitions may consist of a wide-range of individuals and organizations and must include major community hospitals in the coalitions of Prince George's County, Montgomery County, Baltimore County, and Baltimore City. In Prince George's and Montgomery counties, the bills direct the coalitions to work with the Statewide Academic Health Centers to increase cancer-related capacity at the major community hospitals. In Baltimore County and Baltimore City, the coalitions must work in conjunction with the major community hospitals to increase cancer-related capacity. DHMH will distribute funds based on incidence and mortality rates to all jurisdictions, with the exception of Baltimore City because its local public health grants are funded from the Statewide Academic Health Center Component.
In the cancer program, the Statewide Academic Health Center Component includes public health and research grants for the University of Maryland Medical Group and the Johns Hopkins Institutions. In conjunction with the Baltimore City Health Department, the academic health centers will form a community health coalition to develop comprehensive cancer plans. Funding for each institution will be a minimum of $2 million plus any additional funds transferred from the Local Public Health Component. To receive a research grant for cancer, the University of Maryland Medical Group and the Johns Hopkins Institutions must submit a research plan and a memorandum of understanding that outlines the State's financial interest in research developments. In addition to the cancer grant, the University of Maryland Medical Group may apply for a tobacco-related diseases research grant if funds are specifically allocated in the budget for that purpose. The University of Maryland Medical Group may also apply for a network grant to enhance quality of care across the State.
Restricting Tobacco Access
With one exception, State law prohibits a person engaged in the business of selling or distributing tobacco products for commercial purposes from selling or distributing those products to minors. The exception applies to the owner or person exercising control over a tobacco vending machine if a minor has bought a tobacco product from a machine that displays a conspicuous label stating the prohibitions and the criminal penalties concerning the distribution of tobacco products to minors.
The issue of minors' access to tobacco products was again debated in the 2000 session. Senate Bill 271 (passed) repeals the vending machine labeling law exception and prohibits the sale of tobacco products through a vending machine unless the vending machine is: (1) located in an establishment that minors are prohibited by law from entering or located in an establishment that is a bona fide fraternal or veterans organization; or (2) operable only through the use of a token, card, or similar device obtained from the owner or an employee or agent of the owner of an establishment. A violator is guilty of a misdemeanor and, on conviction, subject to a fine not exceeding $100. It is estimated that vending machine sales in Maryland currently represent about one percent to two percent of total cigarette sales. The effect of Senate Bill 271 was contingent on the failure of Senate Bill 899.
Senate Bill 6 (passed) prohibits a retailer or vending machine operator from purchasing from a tobacco product manufacturer or selling, reselling, distributing, dispensing, or giving away to any person a package of cigarettes that contains less than 20 cigarettes. A wholesaler may not sell, resell, distribute, dispense, or give away to any person a package of cigarettes containing less than 20 cigarettes.
Improving Medical Access
The Maryland General Assembly passed legislation to improve access to health care for citizens without access to health care coverage and those that have had difficulty utilizing available coverage.
Maryland Health Programs Expansion Act of 2000
Chapter 110 of 1998 established the Children and Families Health Care Program (program) pursuant to the federal Children's Health Insurance Program (Title XXI of the federal Social Security Act). The State's program provides health insurance coverage for children with family incomes up to 200 percent of the federal poverty guidelines (FPG) through enrollment in HealthChoice. Implemented in July 1998, Maryland's program currently covers over 63,000 children.
Senate Bill 863/House Bill 2 (both passed) repeal the "family contribution" requirement, which would have called for program enrollees whose family incomes are at or above 185 percent but at or below 200 percent of the federal poverty guidelines to pay a portion of their medical premium.
Also, the bills establish a private option plan that allows children whose family income is greater than 200 percent and at or below 300 percent of the FPG to receive subsidized health insurance either through employer-sponsored health benefit plans or through a HealthChoice managed care organization. In addition, the bill augments Medicaid income eligibility for pregnant women from 200 to 250 percent of the federal poverty guidelines. For more detail on this program see Health Insurance in this Part.
Governor's Wellmobile Program
The Governor's Wellmobile Program (program) was established in 1994 and is operated and staffed by the University of Maryland, School of Nursing. Currently, the School of Nursing owns and operates two Wellmobiles equipped with exam rooms, laboratory space, and reception areas. The Wellmobiles deliver primary and preventive health care services in Baltimore City, in Central Maryland, and on the Eastern Shore. Services include physical exams, health education, smoking cessation programs, immunizations, well-child care, diagnosis and treatment of common illnesses, lab tests, and a range of adult and women's services. The program services an average of 30 patients per day or 7,500 annually. Since 1999, the program has been funded through various private grants.
Senate Bill 802/House Bill 433 (both passed) codify and expand the program statewide. Program expansion is expected to increase expenditures by approximately $2.3 million in fiscal 2001 for the purchase of five new Wellmobiles and staff. The bills create a nine-member Governor's Wellmobile Program Advisory Board to assist the School of Nursing in overseeing and raising funds for the program.
Medical Assistance
Expedited Eligibility: Senate Bill 395/House Bill 866 (both passed) require DHMH to implement an expedited eligibility for any individual who applies for the Maryland Children's Health Program through a local health department. "Expedited eligibility" is a streamlined process for determining eligibility that must be completed within ten working days of the date of application. Pregnant women and children have faced barriers to enrollment in HealthChoice when they are receiving or are applying for other forms of assistance, such as food stamps, medical assistance, and cash assistance.
Continuity of Care: Senate Bill 359/House Bill 950 (both passed) require DHMH to establish mechanisms to ensure that a participant in HealthChoice is able to select and keep his or her primary care provider, even if that provider has left the recipient's managed care organization and contracted with another managed care organization. Under the bills, an enrollee may maintain continuity with a selected primary care provider if the primary care provider terminates the contract with the managed care organization under certain circumstances, but has a contract with another managed care organization; the managed care organization terminates its contract with the department; or the managed care organization is acquired by another entity and the provider contract between the provider and the managed care organization is terminated.
Pharmacy Assistance: The Maryland Pharmacy Assistance Program is for low income individuals who would otherwise not be able to afford prescription drugs for treatment of illnesses. According to the American Association of Retired Persons, there are 14 states with pharmacy assistance programs. Maryland and Wyoming are the only states without specific age or disability eligibility requirements. Maryland is, however, one of the more stringent states for income eligibility criteria. Senate Bill 621 (passed) requires the Secretary of DHMH to develop a program that will provide information to ineligible Maryland Pharmacy Assistance Program applicants regarding other programs that they may be eligible for, including free programs offered by drug manufacturers. The bill requires the Secretary, in cooperation with specified agencies and persons, to study and report on the possibility of a buy-in prescription assistance program for the elderly who are eligible for the Pharmacy Assistance Program. The Secretary must report to the Governor and the General Assembly by December 31, 2000.
Long-Term Care: Senate Joint Resolution 4 (passed) request the U.S. Congress to amend Title XIX of the Social Security Act to allow assets exempted under a state's long-term care partnership program to be excluded from Medicaid estate recoveries. Federal law requires a state to seek recovery from an individual's estate for medical assistance paid to a nursing facility or for other long-term care services.
The Partnership for Long-Term Care Program (Chapter 513 of 1993) sought to encourage individuals to purchase long-term care policies for the purpose of qualifying for Medicaid without exhausting all of one's resources. Chapter 442 of 1996 postponed the implementation of the Maryland Partnership for Long-Term Care Program until federal law allows an exemption from the Medicaid estate recovery requirements. Currently, an individual must spend assets down to $2,500 to be eligible for Medicaid coverage for nursing home care. The Partnership for Long-Term Care Program would have allowed individuals with long-term care policies to maintain assets in an amount equal to the benefits paid to nursing facilities under the long-term care policy. The U.S. Congress subsequently passed amendments to Section 1917 of Title XIX that require a state to recover Medicaid costs paid to a nursing facility for an individual, whether or not the individual has a long-term care policy.
Substance Abuse Assistance
The Committee on Availability and the Committee on Effectiveness within the Task Force to Study Increasing the Availability of Substance Abuse Programs (the SIASAP Task Force) found that there was insufficient treatment capacity in Maryland to address substance abuse. The committees recommended that Maryland establish a statewide treatment system which allows for coordinated care, efficient funding streams, improved access for the uninsured and improved accountability. The fiscal 2001 budget funds a number of substance abuse programs in DHMH, the Departments of Human Resources, Public Safety and Correctional Services, and Juvenile Justice.
The General Assembly acted to further increase treatment capacity through Senate Bill 743/House Bill 1205 (both passed) which establish the Substance Abuse Treatment Outcomes Partnership Fund. The fund is placed in DHMH and will make grants available to counties that submit proposals for substance abuse treatment programs. Participating counties must provide a local match of 50 percent, although DHMH may waive some or all of that requirement under certain circumstances. Counties may apply for funds to make substance abuse treatment programs available to inmates, mothers of drug-addicted infants, foster care children and parents, first time drug offenders, pretrial correctional inmates and other at-risk populations. DHMH is required to consult with the SIASAP Task Force when evaluating proposals and awarding partnership funds. The Governor is required to include $4 million for fiscal 2002, $8 million for fiscal 2003, and $12 million for fiscal 2004 to finance the fund.
The Integration of Child Welfare and Substance Abuse Treatment Services Act, House Bill 7 (passed) requires the Department of Human Resources (DHR) and DHMH, in consultation with a broad range of child welfare professionals, to develop a statewide protocol for integrating child welfare and substance abuse treatment services on or before December 1, 2000.
The protocol addresses training requirements for substance abuse treatment and child welfare personnel and requires the Secretaries of DHR and DHMH to enter into a memorandum of understanding on or before June 30, 2001, to implement the provisions of the bill. For more detail see Part M - Human Resources of this 90 Day Report.
Senate Bill 864/House Bill 1267 (both passed) establish the Drug and Alcohol Treatment to Work Pilot Program. The legislation requires the Alcohol and Drug Abuse Administration (ADAA) in DHMH to establish a three-year pilot program to provide one year of training or employment related to the provision of lead abatement services to individuals aged 18-34 who have completed an inpatient drug or alcohol rehabilitation program. Participation is limited to 100 individuals, 80 percent from Baltimore City and Prince George's County and 20 percent from Allegany, Dorchester, Somerset, Wicomico, and Worcester counties. The bills' aim is to address two serious problems in the State: (1) a shortage of qualified personnel to do lead abatement and protect children from the hazards of lead poisoning; and (2) the provision of training, employment, and support to individuals in recovery from substance abuse.
Short-Term Prescription Drug Subsidy Plan
Senate Bill 855 (passed) addresses the increasing need to provide adequate prescription drug coverage to Medicare enrollees, particularly to those residing in medically underserved counties. Medicare is the nation's largest health insurance program, covering approximately 39 million Americans. It provides health insurance to people aged 65 and over, those who have permanent kidney failure, and certain people with disabilities. Medicare does not, however, provide any type of prescription benefits. Instead, Medicare enrollees may purchase supplemental health insurance plans that include prescription drug benefits. Supplemental plans that include drug benefits are often cost-prohibitive for those with limited incomes.
This bill establishes a short-term prescription drug subsidy plan for certain Medicare enrollees who live in medically underserved counties. Enrollment is limited to 15,000 individuals annually. The bill specifies certain premiums, copayments, deductibles, and annual maximum benefit allowances. The prescription drug subsidy plan will be abrogated the earlier of June 30, 2002, or when Medicare provides prescription drug benefits for its enrollees. For more detail on this plan see Health Insurance in this Part.
Health Risks - Reducing Exposure
The General Assembly acted to address the concerns of health care workers and the general public about the risk of exposure to disease or death from unsafe products, exposure to pathogens, and inadequate health care.
Bloodborne Pathogens
Senate Bill 553/House Bill 360 (both passed) require the Commissioner of Labor and Industry in consultation with DHMH to adopt regulations that implement the federal bloodborne pathogen standard in effect as of November 5, 1999. For a more detailed discussion of health care workplace safety, please see the Labor and Industry section under Part H, Business and Economic Issues.
Senate Bill 554/House Bill 845 (both passed) establish reporting requirements for Hepatitis C beginning July 1, 2001. Of the six known forms of Hepatitis, Hepatitis C is considered the most serious form of the disease. Hepatitis C is spread through contaminated blood. Besides health care workers, people at risk include those with body piercing with unsterilized instruments, those with tatoos and those who share items like razors or toothbrushes which contain infected blood. The bills require medical directors to report the occurrence of Hepatitis C in human laboratory specimens analyzed by medical laboratories.
Reducing Meningitis Exposure
To address the alarming incidences of meningococcal disease among college students who reside in on-campus housing, the General Assembly enacted Senate Bill 653/House Bill 227 (both passed). The bills require on-campus resident students enrolled in higher education institutions to be vaccinated against meningococcal disease. Adult students and the parents of minor students may refuse the vaccine after being fully informed of the risks from disease and the availability and effectiveness of the vaccine. An estimated 100 to 125 cases of meningococcal disease occur annually among Maryland students and 5 to 15 deaths result from the disease.
The General Assembly also acted to reduce exposure to disease in the health care institution setting. House Bill 846 (passed) provides immunization protection against influenza and pneumonia for nursing home residents and influenza immunization for employees of related institutions. For a detailed discussion about immunization concerns in health care institutions, please see Health Care Facilities and Regulation in this Part.
Lead Exposure Abatement
Childhood lead poisoning is the number one environmental hazard facing children. Each year over 6,000 children in Baltimore City are diagnosed with dangerous lead levels and 1,200 children are diagnosed with lead poisoning. Baltimore City's lead poisoning rate is over 15 times the national average and Maryland's lead poisoning rate is almost seven times the national average. In 1998, 31.2 percent (17,753) of the children under the age of six in Baltimore City received a blood lead test. Of these children,
22 percent had an elevated blood lead level and 3.8 percent had lead poisoning. The high lead poisoning rate in Baltimore City is due to a high percentage of pre-1950 housing, a high percentage of rental housing, a high concentration of low-income communities, and a failure by government agencies to enforce existing laws aimed at reducing lead poisoning.
Childhood lead poisoning affects both student academic performance and juvenile delinquency. Children who are poisoned by lead are seven times more likely to drop out of school and five times more likely to suffer from learning disabilities. This tends to increase special education costs, lower student academic performance, and increase juvenile delinquency.
Senate Bill 712/House Bill 1221 (both passed) require children residing in areas designated as at risk for lead poisoning to receive a blood test for lead poisoning. The Secretary of the Department of Health and Mental Hygiene must require providers caring for children in such areas to administer blood tests to children by ages 12 months and 24 months, and to children over age 24 months who have not received a blood test for lead poisoning. The bill provides a waiver of blood lead testing for religious reasons.
Medical laboratories must report blood lead test results to the Department of the Environment and in Baltimore City to the Commissioner of the Baltimore City Health Department. The Commissioner of the Baltimore City Health Department is authorized to report the test results to the Baltimore Immunization Registry and to an immunization registry subsequently developed by the Department of Health and Mental Hygiene. By September 2003, parents and legal guardians of children residing in areas designated as at risk for lead poisoning must provide proof that their children have received blood lead testing at the time the child enters a public prekindergarten program, kindergarten program, or first grade.
The fiscal 2001 State budget includes an additional $500,000 in general funds to augment the State's existing program to prevent lead poisoning in children and to expand the State's existing testing program for lead. However, these funds are targeted primarily for Baltimore City. An additional $500,000 in general funds may be needed to ensure that all children residing in a designated at-risk area receive a blood lead test. For more detail on the funding for lead poisoning prevention in the fiscal 2001 budget see Part A - Budget and State Aid of this 90 Day Report.
Exposure in Beauty Salons
Since July 1999, Maryland law has prohibited the use of methyl methacrylate liquid monomer in beauty salons. This compound, at one time used in artificial nail products, has caused injuries, infections, allergic reactions, deformity of fingernails and contact dermatitis. For nail technicians and their clients, methyl methacrylate liquid monomer can also cause respiratory distress, nerve damage, lung, liver and heart damage, and kidney lesions. House Bill 135 (passed) further restricts access to methyl methacrylate monomer by prohibiting any person from selling this compound to beauty salons. The bill does not restrict the use of methyl methacrylate monomer by health care professionals.
The Risk of Maternal Mortality
The risk of maternal death has been cited as a serious public health concern by the Centers for Disease Control. The incidence of maternal mortality is particularly acute in Maryland. Under current law, there is no statutory body charged with investigating causes of maternal death. These deaths are significantly under reported due to concerns over civil litigation or criminal prosecution. Through Senate Bill 459/ House Bill 515 (both passed), Maryland becomes one of over 25 states that have established or reestablished maternal mortality review committees, intended to document and address the causes of maternal mortality. The bills require DHMH to identify maternal death cases, review records and data, consult with experts and make recommendations regarding prevention of maternal death. The bills terminate September 30, 2003.
Developmental Disability Mortality Review
A 12-member Mortality Review Committee within DHMH is established through House Bill 1268 (passed). The bill requires the department to evaluate deaths in facilities or programs licensed by the Developmental Disabilities Administration. The committee is charged with identification of systemic problems and patterns of inadequate care. The committee must make recommendations to the Secretary regarding prevention of avoidable deaths and improvement of overall quality of care.
Miscellaneous Health Measures
Oral Cancer
Relative survival rates for oral cancer are among the lowest of all major cancers, with a 50 percent five-year survival rate. The survival rate has not increased over the past 16 years and tobacco use is strongly linked to the incidence of oral cancer. This and other associated risk behaviors are high in minority populations, where the survival rate for oral cancer has decreased in contrast to the increase in the overall survival rates for other major types of cancer in the nation. House Bill 1184/Senate Bill 791 (both passed) require the Secretary of DHMH to establish the Oral Health Program to prevent and detect oral cancer in Maryland through the training of health care providers in proper screening and referral and through the promotion of smoking cessation. The bills also establish a pilot program to screen, refer, and treat high-risk underserved adults. The pilot program terminates September 30, 2003.
Medical Records
Senate Bill 371 (passed), the result of an ad hoc interim subcommittee, prohibits the disclosure by sale, rental or barter of any medical record. Patients or interested parties must be notified of the transfer of health records. The bill also requires payors to accept claims only from clearinghouses accredited by the Electronic Healthcare Network Accreditation Commission or certified by the State Health Care Commission. The bill authorizes the use of "personal notes" that are intended to grant patients and mental health providers greater privacy, while protecting the third party payor's right to analyze diagnoses and treatment plans for payment authentication. The bill also creates a State Advisory Council on Medical Privacy and Confidentiality. The council is comprised of 29 voting members from the legislature, State agencies, the legal and health care professions, and the information technology industry.
Another confidentiality measure, House Bill 1115 (passed) authorizes pharmacies to maintain a record of prescriptions requested by patients. However, a record log that is available to other pharmacy customers may not list the social security numbers, the types of illnesses or conditions being treated, or the types of drugs dispensed by a pharmacy.
Spinal Cord Injuries
House Bill 300 (passed) establishes an 11-member State Board of Spinal Cord Injury Research and a Spinal Cord Injury Research Trust Fund. The trust fund will be a continuous, nonlapsing fund set up to receive $1,000,000 annually from the premium tax imposed on health insurers beginning January 15, 2002. Grants may be awarded to entities conducting spinal cord injury research focused on basic, preclinical, and clinical research for developing new therapies to restore neurological function in individuals with spinal cord injuries. The bill requires the board to submit yearly reports, develop criteria for awarding grants for spinal cord injury research, make recommendations for grants, and administer the fund.
Health Care Providers
Health Care Credentialing Study
Credentialing organizations have a profound impact upon the ability of health care professionals to practice by determining at which facilities individual practitioners may work. In the past few legislative sessions, there has been an increase in the number of bills introduced relating to credentialing. During the 2000 session, five credentialing bills were introduced. Four bills required hospitals to implement credentialing processes for certain health care professionals, including nurse anesthetists, nurse midwives, and social workers, while the fifth bill related to discrimination in credentialing decisions. To address these sensitive issues in an unbiased manner, aspects of the five bills were included in Senate Bill 328 (passed). The bill directs the Schaefer Center for Public Policy at the University of Baltimore to conduct a Health Care Credentialing Study. This study will include a review of federal and State law regarding hospital policies, procedures, and requirements related to credentialing to ensure that there is adequate opportunity for redress of complaints by health care professionals about exclusion by hospitals and credentialing organizations. The Schaefer Center must submit a report on its findings and recommendations within 60 days of completing the study.
Bloodborne Pathogen Standard
Chapter 408 of 1999 required the Department of Health and Mental Hygiene (DHMH) to convene a study group to review Maryland's bloodborne pathogen standard governing occupational exposure. In its December 1999 report, the study group found that the current bloodborne pathogen standard has not been effective in protecting health care workers from sharps injuries; i.e., injuries resulting from objects (e.g., needles) which can penetrate the skin or other part of the body and expose the workers to harm. Legislation was introduced during the 2000 session that required revision of the State's bloodborne pathogen standard. During conference committee deliberations, the General Assembly decided to adopt the more stringent federal bloodborne pathogen standard rather than revise Maryland's existing standard.
Senate Bill 553/House Bill 360 (both passed)require the Commissioner of Labor, in consultation with the Secretary of DHMH, to adopt regulations to implement the bloodborne pathogen standard established by the federal Occupational Safety and Health Administration (OSHA) as of November 5, 1999. The OSHA standard requires employers to adopt exposure control plans and to use engineering controls and work practices that include safer medical devices, work practices, administrative controls, and personal protective equipment.
Physician Self-Referrals
Under current law, physicians are prohibited from referring patients to a health care facility in which the physician has a financial interest. This prohibition against "physician self-referral" is designed to avoid conflict of interest regarding medical decisions and to discourage overutilization of services. Federal law includes specific exceptions to this prohibition to accommodate legal business arrangements. These exceptions were not included in State law, because Maryland's "physician self-referral" law predates federal action on this issue.
Legislation was introduced during the 2000 session to conform Maryland law to the prevailing federal standards. Senate Bill 211/House Bill 214 (both passed) incorporate three specific federal exceptions into Maryland law: (1) the rental of office equipment at fair market value; (2) isolated transactions such as the sale of a physician practice; and (3) referral to a hospital that the practitioner has a financial interest in, if the practitioner can practice there and if the practitioner's financial interest is in the whole hospital and not a subdivision of the hospital. By conforming Maryland law with federal standards, Senate Bill 211/House Bill 214 reduce uncertainty for physicians in creating new business arrangements and provide new options and flexibility in the reorganization of hospitals.
Dentists and Dental Hygienists
In response to growing evidence of a shortage of dental providers, particularly in rural areas of the State where dental clinics are being forced to close because of insufficient staff, Senate Bill 691/House Bill 1107 (both passed) establish two retired volunteer licenses. These new volunteer licenses will allow dentists and dental hygienists to volunteer their needed services without having to pay to keep their general license current. There is no annual fee for the volunteer licenses. To qualify for a retired volunteer license, a dentist or dental hygienist must have held a general license to practice dentistry or dental hygiene within the last two years, complete the continuing education requirements established for a general license, provide dental services in a government, non-profit, or approved facility serving the poor, the elderly, or the disabled, and agree not to practice dentistry for profit. Retired volunteer dentists and dental hygienists must also maintain malpractice insurance.
Nursing
Statewide Commission on the Crisis in Nursing
Maryland faces a growing nursing shortage due to the expansion of employment opportunities in all settings, decreased enrollment in nursing programs, the aging of the nursing workforce, the aging of the baby boomer generation, the rapid expansion of demand for new roles in nursing, and the rising acuity level of patients. After two years of stagnated growth in the nursing population, the number of nurses in Maryland with active licenses decreased by 2,234 in 1999.
In order to bring together interested and affected parties to address the shortage and develop collaborative remedies, Senate Bill 311/House Bill 363 (both passed) create the Statewide Commission on the Crisis in Nursing. The commission will be composed of representatives from State government, nursing schools, hospitals, nursing homes, managed care organizations, physicians, unions, advocacy organizations, and practicing nurses from several nursing specialty areas. The commission will determine the current extent and long-term implications of the growing nursing personnel shortage, develop recommendations on facilitating and implementing strategies to reverse the nursing shortage, convene a Crisis in Nursing Summit, and serve as an advisor to public and private entities for implementing the commission's recommendations.
Probationary Nursing Licenses
Under current law, the State Board of Nursing may deny a license to any applicant, but cannot grant a probationary license to an applicant or to the holder of a current nursing license. House Bill 1047 (passed) gives the State Board of Nursing the option of issuing a probationary license while making a final decision about the licensure of an applicant. Probationary licenses are currently granted to certain physicians by the Board of Physician Quality Assurance.
Nursing Assistants in the Rehabilitation Program
House Bill 1051 (passed) extends participation in the State Board of Nursing's Rehabilitation Program to certified nursing assistants. Established in 1989, the program assists nurses with substance abuse or serious mental health problems and ensures that participating nurses stay drug and alcohol free and practice their profession safely. House Bill 1051 will provide certified nursing assistants with the same alternative to formal discipline by the Board of Nursing that is currently available to nurses. As the number of certified nursing assistants in the Maryland workforce increases, the ability to refer them to the program will be a valuable option for the board.
Practice Acts
Several bills were introduced during the 2000 session to update or expand the practice acts of specific health care professionals, including physical therapists, occupational therapists, and social workers.
Physical Therapy
House Bill 355 (passed) makes several revisions to the Physical Therapy Practice Act with implications for practitioners and the Board of Physical Therapy Examiners. The bill requires physical therapists and physical therapist assistants whose licenses have been suspended or revoked to return their licenses to the Board.
House Bill 355 also grants the Board of Physical Therapy Examiners several new powers currently held by other health occupations boards. These expanded powers include:
(1) the authority to disclose information to other health occupations regulatory boards if the information is based on final decisions made by the board; (2) the ability to delegate authority to conduct an evidentiary disciplinary hearing to a committee consisting of three or more board members; and (3) the authority to waive the preceptorship requirement for applicants that are currently licensed in another state.
Occupational Therapy
Under current law, the definition of occupational therapy is very general and the scope of practice is focused on occupational therapists who practice in hospital settings. The advent of managed care and the growing trend toward treatment in home health care settings require more specific guidance in occupational therapy practice than is currently provided. Senate Bill 375/House Bill 785 (both passed) update the statutory framework for the practice of occupational therapy and the operations of the State Board of Occupational Therapy. The bills clarify the licensing requirements for occupational therapists, define the scope of practice of an occupational therapy aide, and clarify and revise the board's disciplinary authority. The revised Occupational Therapy Practice Act more accurately reflects current practice and is based on the national legislative model of the American Occupational Therapy Association.
Social Work
Senate Bill 693/House Bill 886 (passed) revise the Maryland Social Workers Act by clarifying the definition and scope of practice of social workers holding each type of license, increase the membership of the State Board of Social Work Examiners due to increased workload, and establish additional grounds for disciplining a licensee for certain conduct. Senate Bill 693/House Bill 886 represent the recommendations of a task force, commissioned by the Board of Social Work Examiners in 1998, to improve the social work statute by addressing long overdue clarification of the scope of each level of licensure. The bills do not broaden the scope of practice in any way.
Health Occupations Boards
Board of Physician Quality Assurance
House Bill 1102 (passed) repeals the requirement that the Board of Physician Quality Assurance must receive a written and signed complaint before investigating an alleged violation of law relating to licensure and regulation of physicians. The bill provides the board with more regulatory authority over physicians who use the Internet in their practice of medicine and allows the board to investigate anonymous complaints from health care workers who may be reluctant to submit written complaints due to concerns over job safety.
House Bill 558 (passed) requires an applicant for a medical license to submit to the board evidence of successful completion of one year of postgraduate medical training in an accredited program. In addition, the bill decreases the number of years, from three to two, of postgraduate medical training a graduate of a foreign medical school must complete. The bill also repeals an exception to postgraduate training requirements for graduates of foreign medical schools who may, under certain circumstances, complete only one year of postgraduate training.
The board has had difficulty in verifying the credentials and educational standards of many of the foreign medical schools included on the list of schools approved prior to July 1, 1992. Eliminating the exceptions based on this list and requiring two years of postgraduate training for all foreign medical graduates will increase quality of control and efficiency by reducing the time spent explaining the current complex requirements.
House Bill 161 (passed) repeals the requirement that the State Board of Physician Quality Assurance administer annual licensure examinations. Until 1999, the board administered "paper and pencil" versions of the national physician licensure examination, the United States Medical Licensing Examination. The last State administered "paper and pencil" exam was given in May 1999. The exam is now a computer-based test administered by the National Federation of State Medical Boards.
State Board of Morticians
Senate Bill 251/House Bill 259 (both passed) prohibit the State Board of Morticians from having more than one member who is employed by or affiliated with the same corporation, professional association, or other entity that owns one or more funeral homes. The bills allows the Governor to remove an appointed member who causes the board to be in violation of this provision. Senate Bill 251/House Bill 259 ensure that no single corporation, association, or other entity can unfairly control the board through disproportionate membership.
State Board of Dental Examiners
In 1999, the General Assembly passed legislation that clarified that the State Board of Dental Examiners was authorized to waive educational requirements only for applicants for limited or teacher's dental licenses. Before enactment of this legislation, the board could waive educational requirements for general dental license applicants as long as they completed two years of formal clinical training. This change was enacted without a grandfather provision, thereby preventing students from foreign jurisdictions who were already enrolled in a two-year dental residency program at the University of Maryland Dental School from qualifying for a waiver. Senate Bill 147 (passed) exempts these individuals, who will complete their dental residencies at the University of Maryland this summer, and allows them to take the State licensure examination for general dentistry on or before December 31, 2000.
State Board of Examiners of Professional Counselors
House Bill 314 (passed) renames the State Board of Examiners of Professional Counselors to be the State Board of Examiners of Professional Counselors and Therapists. The bill also renames the board's fund to be the State Board of Examiners of Professional Counselors and Therapists Fund. Changing the name of the board is intended to assist licensed marriage and family therapists in educating the general public and insurance carriers about their role as mental health providers and allow them greater access to provider panels.
Sunset Extensions
Three bills were introduced during the 2000 session to extend the sunset date of certain health occupations boards. The bills were introduced in response to the recommendations and findings of the sunset review and evaluation process conducted by the Department of Legislative Services and will ensure the continuation of the boards' mandated responsibilities of protecting the citizens of Maryland through their credentialing, examination, licensing, and disciplinary processes.
Senate Bill 574/House Bill 573 (passed) extend until July 1, 2012, the termination date for the State Board of Podiatric Medical Examiners.
Senate Bill 573/House Bill 575 (passed) extend until July 1, 2012, the termination date for the State Board of Chiropractic Examiners.
Senate Bill 572/House Bill 576 (passed) extend until July 1, 2012, the termination date for the State Board of Physical Therapy Examiners.
Health Care Facilities and Regulation
Long-Term Care
Nursing Home Reform
The General Assembly passed several bills this year to implement the recommendations of the Task Force on Quality of Care in Nursing Facilities, which was created by legislation enacted in 1999 (Chapters 382 and 383, Acts of 1999). The task force was charged with examining current quality of care standards for nursing facilities, staffing patterns and standards for nursing facilities, and the status of the labor pool available to fill nursing jobs at those facilities. The task force was also charged with making recommendations to the General Assembly regarding changes to current standards, policies, and procedures as necessary to ensure quality of care in nursing facilities. The findings and recommendations of the task force are set forth in the Report of the Task Force on Quality of Care in Maryland Nursing Facilities, which was issued in December 1999.
Sanctions and Penalties: Senate Bill 689/House Bill 634 (both passed) are emergency bills that increase the civil money penalties that the Secretary of the Department of Health and Mental Hygiene (DHMH) may impose on a nursing home when a deficiency or an ongoing pattern of deficiencies exists at the nursing home. Under current law, if a serious or life-threatening deficiency exists, DHMH may impose civil money penalties that do not exceed a total of $5,000 per day or $50,000 in total. Senate Bill 689/House Bill 634 increase these civil penalties. For deficiencies with a potential for more than minimal harm, the penalties may not exceed $10,000 per instance or $1,000 per day. Civil penalties for deficiencies where there is actual harm to a resident may not exceed $10,000 per instance or $5,000 per day. Civil penalties where there is a serious and immediate threat of harm may not exceed $10,000 per instance or $10,000 per day for an ongoing pattern of deficiencies. The civil penalties are calculated and imposed until DHMH verifies corrective action by the nursing home and sustained compliance on the part of the nursing home.
The bills define the term "deficiency" to mean a condition existing in a nursing home or an action or inaction by the nursing home staff that results in the potential for
more than minimal harm, actual harm, or a serious or immediate threat of harm to one or more residents. The term "ongoing pattern" is defined to mean the occurrence on two consecutive site visits of a deficiency indicating a potential for more than minimal harm or greater. The site visits can be the result of an annual survey, follow-up visits, unscheduled visits, or complaint investigations. DHMH is given the explicit authority, if a deficiency exists in a nursing home, to impose sanctions that may include direction of a plan of correction, the imposition of adequate staffing levels, the appointment of an independent monitor, or the imposition of civil money penalties.
Senate Bill 689/House Bill 634 authorize the department to appoint an independent monitor as an intermediate sanction that may be in addition to or in lieu of any of the other authorized sanctions. The monitor's duties may include periodic inspections of the nursing home to assess the facility's degree of compliance with State and federal regulations and the reporting of the monitor's findings to DHMH and the nursing home. The nursing home is responsible for the costs associated with the appointment of a monitor.
Senate Bill 689/House Bill 634 specify that if a nursing home appeals a civil money penalty, the funds are to be deposited in an interest-bearing escrow account at the nursing home's expense. If the penalty is upheld, the monies must be released to DHMH within 15 days from the date of the decision. If the penalty is reversed, the escrow funds are to be released to the nursing home within 15 days from the date of the decision. Monies derived from the penalties are to be retained by DHMH in a Health Care Quality Account established under the bills. The monies in the account must be used for training, grant awards, demonstration projects, or programs designed to improve quality of care for nursing home patients.
Quality of Care and Inspections: Federal law requires the Office of Health Care Quality (OHCQ) in DHMH to survey each Medicare and Medicaid certified nursing home at least every 9 to 15 months and requires the State to have an overall 12-month average. All surveys are unannounced. Current State law requires OHCQ to conduct at least two unannounced surveys each year of each nursing home. In order to ensure that OHCQ has sufficient resources to conduct all required surveys, the fiscal 2001 budget includes funds for an additional staff of 27.
Senate Bill 688/House Bill 749 (both passed) continue the requirement that OHCQ make a site visit and conduct a full survey of each licensed nursing home at least twice each calendar year. However, the bills allow OHCQ to waive this requirement for any nursing home that, in the two most recent surveys, has had no deficiencies with a potential for minimal harm or greater. This waiver will allow OHCQ to focus its resources on those facilities that are out of compliance.
Staffing: Senate Bill 794/House Bill 784 (both passed) state that it is the intent of the General Assembly that the Governor include $10 million in the State budgets for fiscal 2002 and 2003 to increase payments in the Nursing Service Cost Center of the State Medicaid nursing home reimbursement formula. The increase is to be used by nursing homes to: (1) increase hours of direct care to residents; (2) increase nursing staff; and (3) increase wages, fringe benefits, and other forms of compensation for personnel providing direct care. The additional funds may not be used by a nursing home to provide an increase in the facility's profit. Each nursing home's expenditures will be subject to audit to ensure that the money is used as required by Senate Bill 794/House Bill 784.
The bills also direct DHMH to reconvene the Medicaid Nursing Home Reimbursement Study Group created in 1998 to review nursing home reimbursement methodology. The bills require the study group to review the existing reimbursement formula and to recommend changes as necessary to ensure that the intent of Senate Bill 794/House Bill 784 is achieved. The study group is required to report its findings to the Senate Finance Committee and the House Environmental Matters Committee by December 1, 2000.
Quality Assurance Programs: Senate Bill 690/House Bill 747 (both passed) require each nursing home, by January 1, 2001, to develop and implement a quality assurance program and to designate a qualified individual to coordinate and manage the program. In addition, each nursing home must have a quality assurance committee that consists of at least the nursing home administrator, the director of nursing, the medical director, a social worker, a licensed dietitian, and a geriatric nursing assistant. The quality assurance committee must meet at least monthly, maintain records of all activities, keep records of committee meetings, and report monthly to the nursing home's ombudsman, residents' council, and family council.
Senate Bill 690/House Bill 747 require each nursing home to establish a written quality assurance plan that: (1) includes procedures for concurrent review of all residents; (2) includes methods for identifying and correcting problems; (3) is readily available to all residents and their families, guardians, or surrogate decision makers; and (4) provides criteria for monitoring nursing care. The quality assurance committee must review and approve the quality assurance plan each year.
In addition, Senate Bill 690/House Bill 747 require each nursing home to designate a physician to serve as medical director and be responsible for monitoring physician services at the nursing home. The medical director is required to report monthly to the quality assurance committee. After consulting with representatives of the nursing home industry and the State Medical and Chirurgical Faculty, the Secretary of DHMH is required to establish qualifications for the medical directors of nursing homes, define the duties of the medical director, and adopt regulations relating to physician accountability for attending physicians who treat residents of nursing homes.
Senate Bill 690/House Bill 747 also require each nursing home to establish: (1) a procedure to provide for the smooth and orderly transfer of residents in the event of the closure of the facility; (2) procedures providing a 30-day notice to residents and their families of the closure of the nursing home and a 15-day notice to residents and their families of the termination of public funding for the nursing home; and (3) a procedure providing immediate notification to the family or guardian of a resident if: (i) an accident involving the resident results in injury and has the potential for requiring physical intervention; (ii) there is a significant change in the resident's physical, mental, or psychosocial status; or (iii) there is a need to significantly alter a resident's treatment.
Finally, the bills authorize DHMH to review the financial and performance records of an applicant for a nursing home license or a management firm under contract with an applicant for a license to determine the ability of the applicant or management firm to comply with laws and regulations governing nursing homes.
Ombudsman Program: Senate Bill 764/House Bill 865 (both passed) require the Secretary of Aging to submit a budget for minimum staffing ratios in the Maryland Long-Term Care Ombudsman Program at the higher of: (1) one full-time ombudsman per 1,000 long-term care beds; (2) 20 hours of ombudsman time per week per area agency; or (3) 10 hours of ombudsman time per week per nursing home. The ombudsman program is currently administered statewide by the Department of Aging but is administered at the county level by 19 local area agencies on aging. The local ombudsman programs are staffed by the equivalent of 18 full-time ombudsmen, as well as numerous volunteers. The ombudsmen visit local nursing homes on a regular basis to familiarize themselves with the home's operations and residents and to address residents' questions and concerns. Under current law, there is no minimum staffing ratio for the program.
Quality of Care Oversight: Senate Bill 698/House Bill 748 (both passed) create a 20-member Oversight Committee on Quality of Care in Nursing Homes to continue the work of the Task Force on Quality of Care in Nursing Facilities, which was established in 1999 (Chapters 382 and 383, Acts of 1999). The oversight committee is charged with: (1) monitoring and evaluating the implementation of the task force recommendations; and (2) evaluating the progress of State nursing homes in improving quality of care. The oversight committee is required to report annually, by December 1 of each year, to the General Assembly. The oversight committee is scheduled to terminate on December 31, 2005.
Continuing Care Retirement Communities
Under current law, continuing care retirement communities (CCRCs) are exempt from having to obtain the certificate of need (CON) required of hospitals and nursing homes. However, the exemption imposes its own set of restrictions: (1) the CCRC may not admit new residents directly to the nursing facility on the CCRC campus, but may only use the nursing facility for independent living residents or assisted living residents of the CCRC; and (2) the number of nursing beds in the CCRC's nursing facility may not exceed 20 percent of the independent living units on the CCRC campus. These restrictions have posed a number of problems for CCRCs. For a recently opened facility, the restriction on direct admission means that the beds in the nursing facility remain mostly unused until independent living residents or assisted living residents need nursing care. For an older facility, the restriction on the number of beds means that aging residents may not have a nursing bed waiting for them when they do need nursing care.
Two bills enacted in the 2000 session are intended to address these difficulties. Senate Bill 403/House Bill 864 (both passed) increase from 20 to 24 percent the restriction on the ratio of nursing beds to independent living units for CCRCs with fewer than 300 independent living units. Facilities with 300 units or more continue to be subject to the 20 percent restriction. Senate Bill 146 (passed) allows a CCRC to directly admit a new resident into the CCRC's nursing facility if the resident pays entrance fees, before entering, that are at least equal to the lowest entrance fee charged for an independent living unit or an assisted living unit. The new resident must, at the time of admission, have the potential for an eventual transfer to an independent living unit or assisted living unit, as determined by the resident's personal physician who is not an owner or employee of the CCRC. The number of residents directly admitted to the nursing facility may not exceed 20 percent of the total number of nursing beds in the facility, and a resident may not be admitted directly if the admission would cause the occupancy of the nursing beds in the CCRC to exceed 95 percent of capacity. Senate Bill 146 terminates on June 30, 2002.
Assisted Living
House Bill 1226 (passed) creates the Assisted Living Facilities Grant Program and authorizes the Board of Public Works, on recommendation of the Secretary of DHMH, to make grants to counties, municipal corporations, and nonprofit organizations for: (1) the conversion of public buildings or parts of buildings to assisted living facilities; (2) the acquisition of existing buildings or parts of buildings for use as assisted living facilities; (3) the renovation of assisted living facilities; (4) the purchase of capital equipment for assisted living facilities; or (5) the planning, design, and construction of assisted living facilities. The program is modeled after two existing grant programs that relate to adult day care facilities and community mental health facilities.
Hospitals
Maryland Hospital Bond Program
In 1985, the General Assembly enacted a bond program for closed or delicensed hospitals. Under the Maryland Hospital Bond Program, following the closure of a hospital, the Health Services Cost Review Commission (HSCRC) may assess a fee on all remaining hospitals to spread the cost of repaying the closed hospital's remaining bond obligations. Hospital rates are increased to cover the bond debt. In 1991, this program was changed to make it inapplicable to the repayment of bonds insured by a municipal bond insurance policy.
Legislation was introduced this year Senate Bill 423/House Bill 706 (both passed) to make the Maryland Hospital Bond Program applicable again to bonds that are insured by a municipal bond insurance policy. As passed by the General Assembly, however, this legislation simply requires the Maryland Health and Higher Education Facilities Authority and HSCRC, in consultation with bond rating agencies, bond insurance companies, the Maryland Hospital Association, and other interested parties, to study changes to the Maryland Hospital Bond Program that will ensure access to affordable capital for Maryland hospitals while providing for the orderly elimination of excess hospital capacity in Maryland. The bills require the Authority and HSCRC to report any findings and recommendations to the General Assembly by December 31, 2000.
"Do Not Resuscitate" Orders
An emergency medical services "do not resuscitate order" (EMS/DNR order) is a physician's written order that, in the event of a cardiac or respiratory arrest of a particular patient, authorizes certified or licensed emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation (CPR). Protocols for the form and use of EMS/DNR orders are established by Maryland Institute for Emergency Medical Services System (MIEMSS) in conjunction with the State Board of Physician Quality Assurance (BPQA). Under current law, these protocols apply to certified or licensed emergency medical services (EMS) personnel.
House Bill 770 (passed) broadens current law relating to EMS/DNR orders by authorizing a health care provider other than a certified or licensed emergency medical services worker to provide, withhold, or withdraw treatment in accordance with an EMS/DNR order, if a health care provider sees either a EMS/DNR order or a valid, legible, and patient-identifying EMS/DNR order bracelet. The bill also requires the Attorney General, in consultation with MIEMSS, the Secretary of DHMH, BPQA, and other interested persons to study the adequacy of the current EMS/DNR form, ways to provide guidance for its use, and the need for educational programs. The Attorney General is required to report the findings of the study to the Senate Judicial Proceedings Committee and the House Environmental Matters Committee on or before December 31, 2001.
Prohibitions Against Self-Referral
Under current law, a health care practitioner may not refer a patient, or direct an employee of or person under contract with the provider to refer a patient, to a health care entity in which the provider owns a beneficial interest, in which the provider's immediate family owns a beneficial interest of 3 percent or more, or in which the provider or the provider's family has a compensation arrangement. Senate Bill 111/House Bill 214 (both passed) create an exception to this prohibition that allows a health care practitioner to refer a patient to a hospital in which the health care practitioner has a beneficial interest, if the health care practitioner is authorized to perform services at the hospital and the ownership or investment interest is in the hospital itself and not solely in a subdivision of the hospital.
Senate Bill 111/House Bill 214 also conform Maryland law to the prevailing federal standards governing self-referrals by physicians as they relate to the rental or lease of equipment and the sale of a health care practice. The bills exempt payments made for the rental or lease of equipment from the definition of "compensation arrangement," if the payments are at fair market value and in accordance with an arm's length transaction. The bills also exempt payments made for the sale of property or a health care practice from the definition of "compensation arrangement," if the payments are at fair market value, are made in accordance with an arm's length transaction, and the remuneration is provided in accordance with an agreement that would be commercially reasonable even if no referrals were made.
Health Care Credentialing
Under current law, each hospital is required to establish a credentialing process for the physicians, nurse anesthetists, nurse midwives, and social workers who are employed by or who have staff privileges at the hospital as a condition of licensure. The Secretary of DHMH is required to establish minimum standards for the credentialing process. This credentialing process conducted by hospitals has a profound impact on the ability of all health care professionals to practice their professions.
Senate Bill 328 (passed) requires the Schaefer Center for Public Policy at the University of Baltimore to study and review federal and State law and hospital policies, procedures, and requirements relating to hospital credentialing, in order to ensure that there is adequate opportunity for the redress of the complaints of physicians, nurse anesthetists, nurse midwives, and social workers relating to their exclusion by hospitals and credentialing organizations. The center is to submit a report on its findings and recommendations to the Governor and the Legislative Policy Committee of the General Assembly within 60 days of the completion of its study, but not later than November 30, 2000.
Integration of Child Welfare and Substance Abuse Treatment Services
Senate Bill 671/House Bill 7 (both passed) require the Secretaries of Human Resources and DHMH, in consultation with a broad range of child welfare professionals, to develop a statewide protocol for integrating child welfare and substance abuse treatment services on or before December 15, 2000. In a provision with specific application to hospitals, DHMH is required to explore the use of excess hospital beds in locating new substance abuse treatment programs. Further discussion of this bill can be found earlier in this part under Public Health.
Patient and Provider Safety in Health Care Facilities
Immunization in Long-Term Care Facilities
With certain exceptions, House Bill 846 (passed) requires that each long-term care facility in the State immunize its residents and employees each year, before December 1, against the influenza virus and pneumococcal disease. New residents or employees accepted or hired after December 1 but before April 1 also must be immunized. The facility must document the immunization received by each resident in the resident's record, and the immunization received by each employee in the employee's personnel file. The resident or employee must give written consent. If a resident or employee refuses to be immunized, the facility must document the refusal and the reason for the refusal. A resident or employee is not required to receive an immunization if the vaccine is medically contraindicated for the resident or employee, the vaccine is against the resident's or employee's religious beliefs, or the resident or employee refuses consent after being fully informed.
Criminal Background Checks of Workers
Current law requires an employer, before hiring a worker to provide care in a nursing home, assisted living facility, group home, adult day care program, hospice program, home health setting, congregate housing, or residential service agency to conduct a background check on the worker, either by applying through the State Criminal Justice Information System (CJIS) for a State-only check or by contracting with a private agency to do a private background check. Under Senate Bill 312 (passed) if an employer in one of these settings requests that a private agency conduct a background check, the agency is required to conduct a background check in each state in which the employer knows or has reason to know the employee worked or resided in the 7 years preceding the application for employment.
The bill also requires that an agency conducting a background check: (1) be licensed by the State as a private detective agency; (2) maintain an errors and omissions insurance policy in an amount of not less than $1 million; (3) offer customer assistance in the use of background checks for employment purposes; and (4) be capable of conducting a check within the State within two working days of a request and, outside the State, within five working days of a request. The agency must also comply with the federal Fair Credit Reporting Act requirement that the employee be issued a statement of findings when adverse information is obtained.
Bloodborne Pathogens
In November 1999, the federal Occupational Safety and Health Administration (OSHA) issued a directive updating the agency's 1992 bloodborne pathogen regulations to encourage the use of "needleless technology." Since 1992, a number of companies have developed so-called "needleless needle" systems for injecting solutions into the bloodstream or removing bodily fluids without placing the health care provider at risk of a needle stick. Senate Bill 553/House Bill 360 (both passed) require the State Commissioner of Labor and Industry, in consultation with the Secretary of Health and Mental Hygiene to adopt regulations to implement the November 1999 OSHA directive. In addition, the Commissioner is required to make recommendations for legislative changes to the House Environmental Matters Committee and the Senate Economic and Environmental Affairs Committee within 30 days of issuing the regulations. See Part H, Business and Economic Issues, Labor and Industry, for a further discussion of this legislation.
Elevator Handrails
House Bill 1103 (passed) allows an income tax subtraction modification under the individual and corporate income tax for 100 percent of the expenses incurred by a taxpayer to purchase and install handrails in existing elevators in health care facilities or any other building in which at least 50 percent of the space is used for medical purposes.
Patient Care Advisory Committees
Under current law, each hospital and long-term care facility must have a patient care advisory committee. Each committee must consist of at least (1) a physician not directly involved in the care of the patient in question, (2) a registered nurse not directly involved in the care of the patient in question, (3) a social worker, and (4) the chief executive officer or a designee from each hospital and each long-term care facility represented on the committee.
Patient care advisory committees, at the request of a person who is responsible for making medical decisions for a patient, advise the person in cases involving life-threatening conditions. Currently, a patient care advisory committee, as a part of its deliberations, is required to consult in appropriate cases with all members of the patient's treatment team, the patient, and the patient's family.
Senate Bill 100/House Bill 108 (both passed) expand current law to require a patient care advisory committee, in cases involving the medical care and treatment of a child with a life-threatening condition, to consult with a medical professional who is familiar with pediatric end-of-life care if a medical professional with that expertise is not already on the committee.
Health Care Commissions
Senate Bill 189/House Bill 138 (both passed) repeal the authority of the Maryland Health Care Commission (MHCC) to develop a payment system for all health care practitioners in the State. Instead, the MHCC is required to promote the availability of information on charges by practitioners and reimbursements by insurance carriers and health maintenance organizations. In addition, the MHCC is required to publish, for the preceding 12-month period: (1) the total reimbursement for all health care services; (2) the total reimbursement for each health care specialty; (3) the total reimbursement for each current procedure terminology (CPT) code; and (4) the annual rate of change in reimbursement for health services by health care specialties and by CPT code. The MHCC is also authorized to publish any other information that the MHCC deems appropriate, including information on capitated health care services.
House Bill 432 (passed) provides that the fees assessed by the MHCC on hospitals, nursing homes, insurers, and health care practitioners, and the user fees assessed by the HSCRC on hospitals, must be used exclusively to cover the actual documented direct costs of the statutory and regulatory duties of the commissions. Under current law, the commissions may use these fees to cover the direct and indirect costs of their statutory and regulatory duties.
Health Maintenance Organizations
Subrogation
Subrogation is the substitution of one party in the place of another who has a lawful cause of action, for the purpose of receiving compensation from a third party tort-feasor. In a recent decision issued by the Maryland Court of Appeals, Victor G. Riemer et al. v. Columbia Medical Plan, Inc., (No. 90, September Term, 1999), the court held that a health maintenance organization (HMO) is barred from pursuing a member for restitution, reimbursement, or subrogation when the member receives damages arising from third-party tort claim. In its decision, the court relied in part on a provision of law (see 19-701(f)(3) of the Health - General Article) that limits an HMO to one of three forms of compensation: (1) a copay; (2) a deductible; or (3) a predetermined periodic premium rate.
In addition, the court noted several provisions of State law that specifically confer a right of subrogation, including a statute that authorizes the State to be subrogated to a cause of action that a Medicaid recipient has against another person. The court ultimately determined that the lack of a similar provision applying to HMOs was proof that "the Legislature did not intend for HMOs to have general subrogation rights against members or subscribers."
Senate Bill 903 (passed) allows a contract between an HMO and a subscriber or a group of subscribers to contain a provision that allows the HMO to be subrogated to a cause of action that a subscriber has against another person to the extent that any actual payments made by the HMO result from the occurrence that gave rise to the cause of action. Similar authority is provided for a nonprofit HMO that exclusively contracts with a group of physicians for the provision of health care services to its enrollees, subject to an established fee schedule for the service provided.
The bill applies to subrogation recoveries recovered on or after January 1, 1976, including cases pending or filed after June 1, 2000, but not to: (1) a case for which a final judgment has been rendered and appeals exhausted; or (2) a matter in which a final written liability insurance settlement has been reached and payment made. The provisions of the bill are expressly severable.
Responsibility for and Regulation of Downstream Risk
In 1995, the National Association of Insurance Commissioners (NAIC) studied arrangements where Integrated Delivery Systems, Physician Hospital Organizations, and Independent Practice Associations contract for a capitation or other risk-assuming payment arrangement, to arrange for or provide all or certain health care services to HMO, Managed Care Organization (MCO), or Medicare Provider Sponsored Organization members. The NAIC concluded that many of these groups were assuming insurance risk and should therefore be regulated as an insurer or a hybrid entity. The NAIC issued a model bulletin in 1995 to advise insurance commissioners of how these arrangements could best be regulated, and drafted a model law in 1998 to assist insurance commissioners with the creation of a regulatory framework for the licensure of all risk-bearing entities.
During the 1998 interim, the Governor along with the Chairman of the House Economic Matters Committee asked the Maryland Insurance Administration (MIA), in consultation with the Maryland Health Care Commission (MHCC) and the Health Services Cost Review Commission (HSCRC), to study the issue of downstream risk arrangements between licensed carriers and subcontracting provider entities such as managed behavioral health care organizations. The MIA delivered its final report to the General Assembly in January 2000.
The MIA report defines downstream risk arrangements as "the transfer by an entity such as an HMO, of the responsibility to pay for certain health care services to another entity, such as a group of health care providers." The actual payment transfer occurs when a fixed sum is paid to the downstream provider, who accepts the risk that the cost of the health care services that the downstream provider must provide may exceed the fixed sum received from the HMO. The transfer of this risk is an outgrowth of managed care, which permits the payment of a fixed sum per patient per month for health care services (capitation).
As highlighted by the NAIC attention to the matter, problems with downstream risk arrangements are not unique to Maryland. The issue, however, has received increased attention in the State because of the financial troubles of a downstream risk contractor on Maryland's Eastern Shore, Doctor's Health, Inc., a provider group, is currently in bankruptcy. According to the MIA, payments to certain providers were suspended because of the bankruptcy proceedings and the legal issues revealed in the proceedings.
When an HMO becomes insolvent, the MIA can take control of the company through receivership proceedings. Generally, in such a receivership, payment for health services is prioritized above the needs of other creditors. However, because the MIA has no jurisdiction over the downstream risk contractor directly, its ability to control the damage done by an insolvent downstream risk contractor is limited.
Senate Bill 497/House Bill 5 (both passed) enhance the ability of the MIA to regulate downstream risk contracts between HMOs and health care provider groups. The bills:
Reimbursement of Non-Contracting Providers
Senate Bill 405 (passed) requires an HMO to pay a claim for a covered service rendered to an enrollee by a health care provider that is not under written contract with the HMO at the greater of:
On request, an HMO must disclose the reimbursement rate to a non-contracting provider. The bill allows a provider to enforce certain provisions on payment to non-contracting providers by filing a complaint with the MIA or by filing a civil action. Under the bill, reasonable attorney fees must be awarded if the provider's complaint is sustained.
Further, the bill requires the HSCRC, in consultation with interested parties, to develop a methodology for ensuring reasonable payment to health care providers not under written contract with an HMO. The HSCRC is required to report on its recommendations by January 1, 2002. The bill applies to health care services rendered on or after October 1, 2000. The provisions of the bill terminate at the end of June 30, 2002.
According to the Maryland Health Care Commission (MHCC) as many as 16 percent of all Marylanders lack health insurance. Several legislative initiatives attempted to address the issue of uninsured and underinsured populations in Maryland.
Maryland Children's Health Program
Chapter 110 of 1998 established the Children and Families Health Care Program pursuant to the federal Children=s Health Insurance Program (Title XXI of the federal Social Security Act). The State=s program provides health insurance coverage for children with family incomes up to 200 percent of federal poverty guidelines (FPG) through enrollment in a Medicaid managed care program (HealthChoice). Implemented in July 1998, the Children and Families Health Care Program currently covers 63,000 children.
Chapter 381 of 1999 (Senate Bill 738) required the Department of Health and Mental Hygiene (DHMH) to study ways to expand eligibility for the program by using private market insurance (private option) coverage. DHMH formed a Technical Advisory Committee (TAC) to study the issue. The TAC recommended targeting the private option expansion to children with family incomes between 200 percent and 235 percent of FPG.
Senate Bill 863/House Bill 2 (both passed) repeal the premium requirement for enrollees whose family incomes are above 185 percent but at or less than 200 percent of FPG.
The bills also establish a private option plan that allows children with family incomes above 200 percent and at or below 300 percent of the FPG to receive subsidized health insurance either through an employer=s health benefit plan or through a HealthChoice managed care organization (MCO). To be eligible for employer-sponsored coverage: (1) a child=s parent or guardian must be enrolled in an employer-sponsored
health benefit plan; (2) the employer must elect to participate in the private option plan; (3) the employer must contribute at least 50 percent of the annual premiums; (4) the employer-sponsored plan must include a benefit package that is equivalent to or better than the State=s Comprehensive Standard Health Benefit Plan (CSHBP) currently offered to small businesses; and (5) the employer=s plan may not impose cost-sharing requirements (other than the premium) on eligible individuals.
Approximately 31,000 uninsured children with incomes between 200 percent and 300 percent of the FPG will be eligible to enroll in the expanded program. However, only 19,600 children are expected to enroll in this plan because the family will be required to pay a monthly premium. A family with an income between 200 percent and 250 percent of the FPG must pay a premium equal to 2 percent of the annual income of a family of two at 200 percent of FPG (currently $37 per month) regardless of the number of children enrolled. Families with income between 251 percent and 300 percent of FPG must pay a premium equal to 2 percent of the annual income of a family of two at 250 percent of FPG (approximately $47 per month) regardless of the number of children enrolled. The State will pay the portion of the premium not paid by the employer and employee. It is estimated that approximately 30 percent, or 5,880 of those who enroll, will enroll through an employer-sponsored plan. The remainder (13,720) are expected to enroll in a HealthChoice MCO.
In addition, the bills expand Medicaid eligibility for pregnant women between 200 percent and 250 percent of FPG. The bills also direct DHMH to report to the Governor and the General Assembly on the implementation of the private option plan by December 1, 2003. Finally, one bill renames the Children and Families Health Care Program to be the Maryland Children's Health Program.
Short-Term Prescription Drug Subsidy Plan
Senate Bill 855 (passed) addresses the increasing need to provide adequate prescription drug coverage to Medicare enrollees, particularly to those residing in medically under-served counties. Medicare is the nation's largest health insurance program, covering approximately 39 million Americans. It provides health insurance to people aged 65 and over, those who have permanent kidney failure, and certain people with disabilities. Medicare does not, however, provide any type of prescription benefits. Instead, Medicare enrollees may purchase supplemental health insurance plans that include prescription drug benefits. Supplemental plans that include drug benefits are often cost-prohibitive for those with limited incomes.
At the end of 1999, the last insurance carrier offering a Medicare managed care plan pulled out of several rural Maryland counties leaving as many as 15,000 seniors with no access to the added benefits of a Medicare managed care plan, most significantly prescription drug coverage. Many of these seniors have since been forced to choose between basic living expenses such as food and electricity to cover the high costs of life-sustaining prescription medications. This program will provide a temporary measure to assist these seniors and will have a long-term beneficial effect on public health costs in Maryland.
Senate Bill 855 establishes a short-term prescription drug subsidy plan for certain Medicare enrollees who live in medically under-served counties. Enrollment is limited to 15,000 individuals annually. The bill specifies certain premiums, copayments, deductibles, and annual maximum benefit allowances. The subsidy plan will be funded by the health insurance carriers that receive a 4 percent differential in hospital rates for participating in the Substantial, Affordable, and Available Coverage (SAAC) program. The total contributions to the fund are $5.4 million in each of fiscal 2001 and 2002. CareFirst BlueCross BlueShield of Maryland is charged with the administration of the prescription drug subsidy plan. The prescription drug subsidy plan will be abrogated the earlier of June 30, 2002, or when Medicare provides prescription drug benefits for its enrollees.
Expanded Coverage for the Uninsured and Underinsured
House Bill 3 (failed) would have provided access to health insurance coverage for individuals who would otherwise be uninsured because of affordability issues, chronic health conditions, or both.
This bill would have established: (1) the Maryland Health Insurance Governing Board; (2) the Maryland Health Insurance Assistance Program (a low income subsidy program); and (3) the Maryland Health Insurance Plan (a high risk pool).
Currently, six states have established low income subsidy programs that provide health insurance to low income individuals who are uninsured and are not eligible for Medicaid. Under the proposal, individuals who are eligible for an employer-sponsored plan would have received a subsidy from the State to participate in the employer-sponsored plan. Under House Bill 3, adults who have incomes below 200 percent of FPG could obtain health insurance premium subsidies.
Twenty-eight states now have health insurance high risk pools, or similar state programs that guarantee access to health insurance for the medically uninsurable population. Under House Bill 3, an individual who would have been turned down for health insurance could obtain affordable health insurance coverage under the Maryland Health Insurance Plan.
Both proposals were to be funded by a fee on hospitals equal to 1 percent of annual gross revenue. Enrollment in either program was limited to the extent that total expenditures could not exceed revenues generated from one fee.
Nonprofit Health Entity Responsibility Act of 2000
There are eight states that have enacted mandatory community benefit laws for nonprofit health entities. Of these, three have established minimum expenditure guidelines for community benefits as a condition of state or local tax exempt status.
All but one hospital in the State of Maryland has nonprofit status. Currently, the only nonprofit health service entity in Maryland is CareFirst BlueCross BlueShield. CareFirst BlueCross BlueShield is the trade name for the 1998 combination of the former Maryland and National Capital Area BlueCross and BlueShield plans. Nationally, BlueCross plans were established during the Great Depression to combat the difficulty in finding health care. The plans were set up to serve a public service role and functioned as nonprofit organizations. The BlueShield plans were established out of employers' desire to provide medical care for their workers.
House Bill 4 (failed) attempted to establish a process to monitor the community benefit activities of nonprofit health benefit plans and hospitals in the State. The bill would have required nonprofit hospitals to submit an annual community benefit report to the Health Services Cost Review Commission (HSCRC) explaining the hospital's community benefits. Under the proposal, community benefits include:
House Bill 4 would have required each nonprofit health service plan to file a premium tax exemption report with the Maryland Insurance Administration (MIA) that demonstrated that the nonprofit health service plan used funds equal to the value of the premium tax exemption in a manner that serves the public interest. Under the bill, if the Insurance Commissioner determined that a nonprofit health service plan had not met the public interest requirements, the nonprofit health service plan would be subject to the premium tax.
Small Group Market Reforms
Senate Bill 801/House Bill 649 (both passed) modify the method for determining employer group size for purposes of inclusion in the small group insurance market. The bills provide that a small employer, when determining its group size, must count an employee who is otherwise covered under a public or private health insurance plan or other health benefit arrangement. Under current law, an employer is prohibited from counting individuals who are otherwise covered when determining group size. However, the bills allow small employers that are currently enrolled in the small group market to maintain eligibility for small group coverage even after the new requirements take effect. The bills also alter the eligibility requirements for the self-employed by requiring self-employed individuals to work and reside in the State in order to be eligible for coverage in the small group market.
In addition, the bills require MHCC, in consultation with the MIA, health insurance carriers, small employers, and insurance agents and brokers, to report on the effect of employer group size on the health maintenance organization (HMO) and preferred provider option (PPO) delivery systems of each prominent carrier in the small group insurance market. MHCC must submit its report to the House Economic Matters Committee and the Senate Finance Committee by January 1, 2001. MHCC must, as part of its annual review of the CSHBP, examine the feasibility and desirability of developing a high deductible health benefit plan for small employers.
House Bill 297 (failed) would have changed the definition of a small employer for the purposes of eligibility in the small group insurance market by excluding self-employed individuals. In addition, the bill would have increased the maximum size of a small business in the small group insurance market from 50 employees to 100 employees. The bill would have imposed a $4,000 annual cap on prescription drug benefits for each covered individual and would have increased the allowable community rate adjustment from 40 percent to 50 percent.
Mandated Benefits and Coverages
Mandated Health Insurance Services - Generally
Mandated benefits are benefits that, by State law, must be covered in a health insurance policy or contract, including mandated offerings. These mandates are required of a commercial insurance carrier, a nonprofit health service plan, an HMO, or any combination of these three. Mandated benefits fall into four categories: (1) health care services or treatments; (2) health care professionals that are entitled to reimbursement; (3) coverage eligibility requirements for dependents; and (4) conversion or continuation of benefits requirements.
Currently, Maryland has 34 mandated benefits or offerings for services and provider reimbursement. 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.
Mandated benefits have an impact on premiums, but only apply to certain segments of the health insurance market. Under the Maryland Health Insurance Reform Act of 1993, a comprehensive standard health benefit package, which is exempted from mandated benefits, has been adopted by regulation for the small group market. However, MHCC, which is charged with developing the Comprehensive Standard Health Benefit Plan for the small group market, considers existing mandated benefits when it performs its annual reassessment of the standard benefit plan. Federal law (ERISA) preempts any state regulation of fully self-insured plans, which are therefore exempt from mandated benefits. Because the federal programs of Medicaid, Medicare, Federal Employees Health Benefits Program (FEHBP), and Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) are not insurance policies, they are not subject to mandated benefits or regulation by the MIA.
Mandated Benefits Review Process
Legislation passed by the General Assembly in 1999 (Chapter 582) established a statutory affordability cap on mandated benefits of 2.2 percent of Maryland's average annual wage. According to MHCC's 1999 report, the full cost of existing mandates is now 1.9 percent of Maryland's average annual wage. If MHCC determines that the full cost of mandated benefits is equivalent to or exceeds the 2.2 percent statutory affordability cap, it is required by law to perform a comprehensive evaluation of each existing mandate and to present this evaluation to the General Assembly for its consideration.
The following mandates passed the General Assembly during the 2000 session:
Coverage for Hair Prostheses
Senate Bill 386/House Bill 22 (both passed) require HMOs, insurers, and nonprofit health service plans to provide coverage up to $350 for a hair prosthesis for an individual whose hair loss results from chemotherapy or radiation treatment. To be eligible for coverage, the prosthesis must be prescribed by an oncologist.
Expansion of In Vitro Fertilization Mandate
Senate Bill 516/House Bill 350 (both passed) provide that HMOs, insurers, and nonprofit health service plans must provide policyholders with coverage for in vitro fertilization services for male factor infertility and reduce the waiting period provided under current law for coverage of infertility services from five to two years. Under the bills, HMOs must provide the benefits to the same extent as for other infertility services.
The bills also allow insurers to limit the infertility coverage required under this bill to three in vitro fertilization attempts per live birth, not to exceed a maximum lifetime benefit of $100,000. The bills further require a carrier to exclude from a policy or contract with a religious organization that has bona fide beliefs and practices that conflict with the coverage requirement, at the organization's request.
A similar bill, House Bill 1031 (failed) would have required in vitro fertilization coverage for unmarried couples. House Bill 1031 would also have required carriers to provide in vitro fertilization benefits in the small group insurance market.
Habilitative Services
House Bill 6 (passed) requires HMOs, insurers, and nonprofit health service plans to provide coverage for habilitative services for children with congenital and genetic birth defects. Habilitative services are defined in the bill as "services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with congenital and genetic birth defects to enhance the child's ability to function." This bill also requires carriers to provide annual notice to their insureds and enrollees about this coverage.
The following mandated benefits failed in the 2000 session, but will be reviewed by the Maryland Health Care Commission in its evaluation, which is due to the General Assembly in December, 2000:
Coverage for Hearing Aids
House Bill 26 (failed) would have required insurance carriers, nonprofit health service plans, and HMOs to provide coverage for an insured or enrollee of a standard model hearing aid every three years.
Senate Bill 268/House Bill 66 (both failed) would have required insurers, nonprofit health service plans, and HMOs to provide coverage of hearing aids for a child who is covered through an insured or enrolled parent of the child.
A similar bill, House Bill 393 (failed) would have required insurers, nonprofit health service plans, and HMOs to provide coverage for hearing aids at least once every three years for a child who is covered through an insured or enrolled parent if the hearing aid is prescribed, fitted, and dispensed by a licensed audiologist.
Coverage for Colorectal Cancer Screening
Senate Bill 174 (failed) would have required insurers, nonprofit health service plans, and HMOs to provide coverage for colorectal cancer screening in accordance with the latest screening guidelines issued by the American Cancer Society.
Coverage for Interpreter Expenses
House Bill 914 (failed) would have required insurers, nonprofit health service plans, and HMOs to reimburse a health care provider for the cost of services performed by a qualified interpreter for an insured or enrollee under certain circumstances.
The Americans With Disabilities Act requires a health care provider to furnish auxiliary aids and services, including interpreters, to ensure effective communication with patients who have disabilities.
Coverage for Morbid Obesity
Senate Bill 496 (failed) would have mandated coverage by insurers, nonprofit health service plans, and HMOs of expenses incurred by a patient classified as "morbidly obese" for established surgical treatment if: (1) all nonsurgical medical therapies, as determined by the physician, have failed; and (2) the body mass index (BMI) of the patient exceeds specified levels.
Coverage for Smoking Cessation
House Bill 1125 (failed) would have mandated that a carrier provide coverage for any medically appropriate treatment or assistance, including drugs, that the insured's or enrollee's treating physician or other appropriate licensed health care provider certifies is necessary for the insured's or enrollee's participation in a smoking cessation program or treatment plan.
Senate Bill 518 (failed) would have mandated prescription drug coverage for up to three "quit attempts" for each enrollee or insured. Insurers, nonprofit health service plans, HMOs, and MCOs would have been subject to the provisions of this bill.
Under the bill, a "quit attempt" means a smoking cessation program that consists of: (1) two office visits; (2) one follow-up telephone call; (3) a two-month supply of approved smoking cessation drugs as prescribed; and (4) two months of counseling or smoking cessation classes as prescribed. The bill does not require coverage for over-the-counter products.
Coverage for Thin Prep Pap Tests
House Bill 200 (failed) would have required insurance carriers, nonprofit health service plans, and HMOs to provide coverage for an annual Thin Prep Pap Test if the patient's gynecologist or internist requests this test.
Internal Appeals and Grievance Processes
Senate Bill 164/House Bill 405 (both passed) require a health insurance carrier to establish an internal complaint procedure for coverage decisions. Under current law, carriers are required to have an established internal appeals process for medical necessity determinations. In addition, the MIA administers an external appeals and grievance process for medical necessity determinations. These bills require a carrier to expand its current internal appeals process to include coverage determinations. In addition, the bills alter current notice requirements with which a carrier must comply when rendering an adverse decision or a grievance decision. The bills enhance the current notice requirements consolidating the information contained in the initial notice to an enrollee.
Provider Panels
Senate Bill 295/House Bill 559 (passed) prohibit, with one exception, a health insurer, nonprofit health service plan, or HMO that contracts with health care providers through one or more provider panels from requiring a provider, as a condition of participation or continuation on a provider panel, to serve on the provider panel of another health benefit plan of the carrier. The definition of provider panel is expanded to include arrangements in which a provider participates solely by contracting with the carrier to provide health care services at a discounted fee-for-service rate. The exception is that a carrier may require a provider to serve on its Medicaid MCO panel. Carriers that have multiple provider panels, in certain cases, condition the participation of a provider on the provider's contractual consent, to serve on one or more of the carrier's other provider panels (commonly known as an "all-products" clause).
The bills also require a carrier to give a provider 90 days' notice before terminating participation on a panel. Under current law, a carrier must give a provider 90 days' notice before terminating the provider from its panel, if the termination is for reasons unrelated to fraud, patient abuse, or loss of licensure status.
Senate Bill 455/House Bill 1068 (passed) require a health insurance carrier to make available a list of the carrier's providers to a prospective enrollee at the time of enrollment and to an enrollee at the time of renewal. The bills change current law to require a carrier to make available a provider list to a prospective enrollee at the time of enrollment (as opposed to the current requirement to provide the list before enrollment) and to an enrollee at the time of renewal (as opposed to the current requirement to provide the list once a year). A carrier must satisfy these requirements by: (1) notifying the enrollee and prospective enrollee about how to obtain the information on the Internet and by ordering a printed copy; and (2) making a printed copy of the provider list available before a prospective employee's enrollment and issuing a printed copy to the enrollee upon the enrollee's initial enrollment. A provider list made available on the Internet must be updated every 15 days. A provider list in printed form must be updated annually.