Code Revision - Health - Maryland Medical Assistance Program

EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets] indicate matter deleted from existing law.
Underlining indicates amendments to bill.
Strike out indicates matter stricken from the bill by amendment or deleted from the law by
amendment.
*sb0244*

SENATE BILL 244
J1 6lr1201
CF HB 529
By: The President (By Request – Department of Legislative Services – Code
Revision)
Introduced and read first time: January 15, 2026
Assigned to: Finance
Committee Report: Favorable
Senate action: Adopted
Read second time: February 7, 2026

CHAPTER ______

AN ACT concerning 1

Code Revision – Health – Maryland Medical Assistance Program 2

FOR the purpose of revising, restating, and recodifying the laws of this State relating to 3
the Maryland Medical Assistance Program; and generally relating to laws relating 4
to the Maryland Medical Assistance Program. 5

BY renumbering 6
Article – Health – General 7
Section 15–103.1 through 15–103.8 8
to be Section 15–103.3 through 15–103.10, respectively 9
Annotated Code of Maryland 10
(2023 Replacement Volume and 2025 Supplement) 11

BY repealing and reenacting, with amendments, 12
Article – Health – General 13
Section 5 –615(c)(2)(vi), 15 –102.5(a), 15 –103, 15 –109(b), 15 –148, 15 –152, 15 –158, 14
15–301(b)(1), and 15–304(b)(2) 15
Annotated Code of Maryland 16
(2023 Replacement Volume and 2025 Supplement) 17

BY adding to 18
Article – Health – General 19
Section 15–103.1, 15–103.2, and 15–305 through 15–309 20
Annotated Code of Maryland 21
2 SENATE BILL 244

(2023 Replacement Volume and 2025 Supplement) 1

BY repealing and reenacting, with amendments, 2
Article – Health – General 3
Section 15–103.5(b)(1) and 15–103.8(a)(2) 4
Annotated Code of Maryland 5
(2023 Replacement Volume and 2025 Supplement) 6
(As enacted by Section 1 of this Act) 7

SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 8
That Section(s) 15–103.1 through 15–103.8 of Article – Health – General of the Annotated 9
Code of Maryland be renumbered to be Section(s) 15 –103.3 through 15 –103.10, 10
respectively. 11

SECTION 2. AND BE IT FURTHER ENACTED, That the Laws of Maryland read 12
as follows: 13

Article – Health – General 14

5–615. 15

(c) (2) The information sheet developed by the Department under this 16
subsection shall be provided by: 17

(vi) A managed care organization in accordance with [§ 15–103] § 18
15–103.1(I)(1)(XVII) of this article; 19

15–102.5. 20

(a) Subject to [§ 15–103(f)] § 15–103.1(DD) of this subtitle, a health maintenance 21
organization that requires its panel providers to participate in a managed care organization 22
shall establish a mechanism, subject to review by the Secretary, which provides for 23
equitable distribution of enrollees and which ensures that a provider will not be assigned a 24
disproportionate number of enrollees. 25

15–103. 26

(a) [(1)] The Secretary shall administer the Maryland Medical Assistance 27
Program. 28

[(2)] (B) The Program: 29

[(i)] (1) Subject to the limitations of the State budget, shall provide 30
medical and other health care services for indigent individuals or medically indigent 31
individuals or both; 32

SENATE BILL 244 3

[(ii)] (2) Shall provide, subject to the limitations of the State budget 1
AND AS PERMITTED BY FEDERAL LAW, comprehensive medical, dental, and other health 2
care services, including services provided in accordance with § 15–141.5 of this subtitle, for 3
all eligible pregnant women whose family income is at or below [250 percent] 250% of the 4
poverty level for the duration o f the pregnancy and for 1 year immediately following the 5
end of the woman’s pregnancy[, as permitted by the federal law]; 6

[(iii)] (3) Shall provide, subject to the limitations of the State budget 7
AND AS PERMITTED BY FEDERAL LAW, comprehensive medical a nd other health care 8
services for all eligible children currently under the age of 1 YEAR whose family income 9
falls below [185 percent] 185% of the poverty level[, as permitted by federal law]; 10

[(iv)] (4) Beginning on January 1, 2012, shall provide, subject to the 11
limitations of the State budget AND AS PERMITTED BY FEDERAL LAW, family planning 12
services to all women whose family income is at or below [200 percent] 200% of the poverty 13
level[, as permitted by federal law]; 14

[(v)] (5) Shall provide, subject to the limitations of the State budget 15
AND AS PERMITTED BY FEDERAL LAW, comprehensive medical and other health care 16
services for all children [from the age of ] WHO ARE AT LEAST 1 year [up through and 17
including] OLD AND UNDER the age of 5 years whose family income falls below [133 18
percent] 133% of the poverty level[, as permitted by the federal law]; 19

[(vi)] (6) Beginning on January 1, 2014, shall provide, subject to the 20
limitations of the State budget AND AS PERMITTED BY FEDERAL LAW, comprehensive 21
medical care and other health care services for all children who are at least 6 years [of age 22
but are] OLD AND under THE AGE OF 19 years [of age] whose family income falls below 23
[133 percent] 133% of the poverty level[, as permitted by federal law]; 24

[(vii)] (7) Shall provide, subject to the limitations of the State budget 25
AND AS PERMITTED BY FEDERAL LAW, comprehensive medical care and other health 26
care services for all legal immigrants who meet Program eligibility standards and who 27
arrived in the United States before August 22, 1996, the effective date of the federal 28
Personal Responsibility and Work Opportunity Reconciliation Act[, as permitted by federal 29
law]; 30

[(viii)] (8) Shall provide, subject to the limitations of the State budget 31
and any other requirements imposed by the State, comprehensive medical care and other 32
health care services for all legal immigrant children under the age of 18 years and pregnant 33
women who meet Program eligibility standards and who arrived in the United States on or 34
after August 22, 1996, the effective date of the federal Personal Responsibility and Work 35
Opportunity Reconciliation Act; 36

[(ix)] (9) Beginning on January 1, 2014, shall provide, subject to the 37
limitations of the State budget, an d as permitted by federal law, medical care and other 38
4 SENATE BILL 244

health care services for adults whose annual household income is at or below [133 percent] 1
133% of the poverty level; 2

[(x)] (10) Subject to the limitations of the State budget, and as 3
permitted by federal law: 4

[1.] (I) Shall provide comprehensive medical care, dental 5
care, and other health care services for former foster care adolescents who, on their 18th 6
birthday, were in foster care under the responsibility of the State and are not otherwise 7
eligible for Program benefits; and 8

[2.] (II) May provide comprehensive medical care, dental 9
care, and other health care services for former foster care adolescents who, on their 18th 10
birthday, were in foster care under the responsibility of any other state or the District of 11
Columbia; 12

[(xi)] (11) May include bedside nursing care for eligible Program 13
recipients; 14

[(xii)] (12) Shall provide services in accordance with funding 15
restrictions included in the annual State budget bill; 16

[(xiii) 1. Beginning on January 1, 2019, may provide, subject to the 17
limitations of the State budget, and as permitted by federal law, dental services for adults 18
whose annual household income is at or below 133 percent of the poverty level; and] 19

[2.] (13) Beginning on January 1, 2023, shall provide, 20
subject to the limitations of the State budget, and as permitted by federal law, dental 21
services for adults, including diagnostic, preventive, restorative, and periodontal services, 22
whose annual household income is at or below 133 percent of the federal poverty level; 23

[(xiv)] (14) Shall provide, subject to the limitations of the State 24
budget, medically appropriate drugs that are approved by the United States Food and Drug 25
Administration for the treatment of hepatiti s C, regardless of the fibrosis score, and that 26
are determined to be medically necessary; 27

[(xv)] (15) Shall provide, subject to the limitations of the State 28
budget, health care services appropriately delivered through telehealth to a patient in 29
accordance with § 15–141.2 of this subtitle; 30

[(xvi)] (16) Beginning on January 1, 2021, shall provide, subject to the 31
limitations of the State budget and § 15–855(b)(2) of the Insurance Article, and as permitted 32
by federal law, services for pediatric autoimmu ne neuropsychiatric disorders associated 33
with streptococcal infections and pediatric acute onset neuropsychiatric syndrome, 34
including the use of intravenous immunoglobulin therapy, for eligible Program recipients, 35
if pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections 36
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and pediatric acute onset neuropsychiatric syndrome are coded for billing and diagnosis 1
purposes in accordance with § 15–855(d) of the Insurance Article; 2

[(xvii)] (17) Beginning on January 1, 2022, may not include, subject to 3
federal approval and limitations of the State budget, a frequency limitation on covered 4
dental prophylaxis care or oral health exams that requires the dental prophylaxis care or 5
oral health exams to be provided at an interval greater than 120 days within a plan year; 6

[(xviii)] (18) Shall provide, subject to the limitations of the State 7
budget, comprehensive medical care and other health care services to noncitizen pregnant 8
women who would be eligible for the Program but for their immigration status and to their 9
children up to the age of 1 year; 10

[(xix)] (19) Shall provide coverage of abortion care services to 11
Program recipients in the manner described in § 15–857(b)(1)(ii) and (2) of the Insurance 12
Article; 13

[(xx)] (20) Beginning on July 1, 2023, shall provide, subject to federal 14
approval and limitations of the State budget, community violence prevention services in 15
accordance with § 15–141.3 of this subtitle; 16

[(xxi)] (21) Beginning on January 1, 2023, shall provide, subject to the 17
limitations of the State budget, and as permitted by federal law, coverage for self–measured 18
blood pressure monitoring for all Program recipients diagnosed with uncontrolled high 19
blood pressure, including: 20

[1.] (I) The provision of vali dated home blood pressure 21
monitors; and 22

[2.] (II) Reimbursement of health care provider and other 23
staff time used for patient training, transmission of blood pressure data, interpretation of 24
blood pressure readings and reporting, and the delivery of c o–interventions, including 25
educational materials or classes, behavioral change management, and medication 26
management; 27

[(xxii)] (22) Beginning on January 1, 2024, shall provide 28
gender–affirming treatment in accordance with § 15–151 of this subtitle; 29

[(xxiii)] (23) Beginning on July 1, 2025, shall provide, subject to the 30
limitations of the State budget, and as permitted by federal law, coverage for biomarker 31
testing in accordance with § 15–859 of the Insurance Article; 32

[(xxiv)] (24) Beginning on January 1, 2025, shall provide coverage for 33
prostheses in accordance with § 15–844 of the Insurance Article; 34

6 SENATE BILL 244

[(xxv)] (25) Beginning on January 1, 2026, shall provide, subject to the 1
limitations of the State budget, and as permitted by federal law, coverage for self–measured 2
blood pressure monitoring for eligible Program recipients in accordance with § 15–141.6 of 3
this subtitle; 4

[(xxvi)] (26) Beginning on January 1, 2026, shall provide coverage for 5
a transfer to a special pediatric hospital in accord ance with § 15–861 of the Insurance 6
Article; 7

[(xxvii)] (27) Beginning on January 1, 2026, if providing coverage 8
for the delivery of anesthesia, shall provide coverage for the delivery of anesthesia in 9
accordance with § 15–862 of the Insurance Article; and 10

[(xxviii)] (28) Beginning on January 1, 2026, shall provide 11
calcium score testing in accordance with § 15–863 of the Insurance Article. 12

[(3)] (C) Subject to restrictions in federal law or waivers, the Department 13
may: 14

[(i)] (1) Impose cost–sharing on Program recipients; and 15

[(ii)] (2) For adults who do not meet requirements for a federal 16
category of eligibility for Medicaid: 17

[1.] (I) Cap enrollment; and 18

[2.] (II) Limit the benefit package. 19

[(4)] (D) Subject to the limitations of the State budget, the Department 20
shall implement the provisions of Title II of the federal Patient Protection and Affordable 21
Care Act, as amended by the federal Health Care and Education Reconciliation Act of 2010, 22
to include: 23

[(i)] (1) Parents and caretaker relatives who have a dependent 24
child living in the parents’ or caretaker relatives’ home; and 25

[(ii)] (2) Adults who do not meet requirements, such as age, 26
disability, or parent or caretaker relative of a dependent child, for a fed eral category of 27
eligibility for Medicaid and who are not enrolled in the federal Medicare program, as 28
enacted by Title XVII of the Social Security Act. 29

[(5)] (E) (1) On or before January 1, 2025, subject to the limitations of 30
the State budget, and as permitted by federal law, the Department: 31

(i) Shall establish an Express Lane Eligibility Program to enroll 32
individuals in the [Maryland Medical Assistance ] Program and Maryland Children ’s 33
SENATE BILL 244 7

Health Program based on eligibility findings by the Supplemental Nutrition Assistance 1
Program; 2

(ii) May not consider any other income or eligibility requirements; 3

(iii) To the extent that a waiver is needed to maximize the number of 4
State residents who may qualify for the Express Lane Eligibility Program, shall apply to 5
the Centers for Medicare and Medicaid Services for one or more waivers under § 1115 of 6
the federal Social Security Act to implement the Express Lane Eligibility Program; and 7

(iv) [Shall] SUBJECT TO PARAGRAPH (2) OF THIS SUBSECTION, 8
SHALL make all reasonable efforts to expedite enrollment of eligible individuals in the 9
Express Lane Eligibility Program [, provided that the Department may propose or 10
implement the use of Express Lane Eligibility for renewals before proposing or 11
implementing the use of Express Lane Eligibility for initial enrollment]. 12

(2) THE DEPARTMENT MAY PROPOS E OR IMPLEMENT THE U SE OF 13
EXPRESS LANE ELIGIBILITY FOR RENEW ALS BEFORE PROPOSING OR 14
IMPLEMENTING THE USE OF EXPRESS LANE ELIGIBILITY FOR INITI AL 15
ENROLLMENT. 16

[(b) (1) As permitted by federal law or waiver, the Secretary may establish a 17
program under which Program recipients are required to enroll in managed care 18
organizations. 19

(2) (i) The benefits required by the program developed under 20
paragraph (1) of this subsection shall be adopted by regulation and shall be equivalent to 21
the benefit level required by the Maryland Medical Assistance Program on January 1, 1996. 22

(ii) Subject to the limitations of the State budget and as permitted 23
by federal law or waiver, the Department shall provide reimbursement for medically 24
necessary and appropriate inpatient, intermediate care, and halfway house substance 25
abuse treatment services for substance abusing enrollees 21 years of age or older who are 26
recipients of temporary cash assistance under the Family Investment Program. 27

(iii) Each managed care organization participating in the program 28
developed under paragraph (1) of this subsection shall provide or arrange for the provision 29
of the benefits described in subparagraph (ii) of this paragraph. 30

(iv) Nothing in this paragraph may be construed to prohibit a 31
managed care organization from offering additional benefits, if the managed care 32
organization is not receiving capitation payments based on the provision of the additiona l 33
benefits. 34

8 SENATE BILL 244

(v) Notwithstanding subparagraph (i) of this paragraph, the benefits 1
required by the program developed under paragraph (1) of this subsection shall include 2
dental services for pregnant women. 3

(3) Subject to the limitations of the State b udget and as permitted by 4
federal law or waiver, the program developed under paragraph (1) of this subsection and 5
the program developed under § 15–301 of this title may provide guaranteed eligibility for 6
each enrollee for up to 6 months, unless an enrollee obtains health insurance through 7
another source. 8

(4) (i) The Secretary may exclude specific populations or services from 9
the program developed under paragraph (1) of this subsection. 10

(ii) For any populations or services excluded under this paragrap h, 11
the Secretary may authorize a managed care organization, to provide the services or 12
provide for the population, including authorization of a separate dental managed care 13
organization or a managed care organization to provide services to Program recipients with 14
special needs. 15

(5) (i) Except for a service excluded by the Secretary under paragraph 16
(4) of this subsection, each managed care organization shall provide all the benefits 17
required by regulations adopted under paragraph (2) of this subsection. 18

(ii) For a population or service excluded by the Secretary under 19
paragraph (4) of this subsection, the Secretary may authorize a managed care organization 20
to provide only for that population or provide only that service. 21

(iii) A managed care organization may subcontract specified required 22
services to a health care provider that is licensed or authorized to provide those services. 23

(6) Except for the Program of All –inclusive Care for the Elderly (“PACE”) 24
Program, the Secretary may not include the lo ng–term care population or long –term care 25
services in the program developed under paragraph (1) of this subsection. 26

(7) The program developed under paragraph (1) of this subsection shall 27
ensure that enrollees have access to a pharmacy that: 28

(i) Is licensed in the State; and 29

(ii) Is within a reasonable distance from the enrollee’s residence. 30

(8) For cause, the Department may disenroll enrollees from a managed 31
care organization and enroll them in another managed care organization. 32

(9) Each managed care organization shall: 33

SENATE BILL 244 9

(i) Have a quality assurance program in effect which is subject to 1
the approval of the Department and which, at a minimum: 2

1. Complies with any health care quality improvement 3
system developed by the Centers for Medicare and Medicaid Services; 4

2. Complies with the quality requirements of applicable 5
State licensure laws and regulations; 6

3. Complies with practice guidelines and protocols specified 7
by the Department; 8

4. Provides for an enrollee grievance system, including an 9
enrollee hotline; 10

5. Provides a provider grievance system; 11

6. Provides for enrollee and provider satisfaction surveys, to 12
be taken at least annually; 13

7. Provides for a consumer advisory board to receive regular 14
input from enrollees; 15

8. Provides for an annual consumer advisory board report to 16
be submitted to the Secretary; and 17

9. Complies with specific quality, access, data, and 18
performance measurements adopted by the Department for treating enrollees with special 19
needs; 20

(ii) Submit to the Department: 21

1. Service–specific data by service type in a format to be 22
established by the Department; 23

2. Utilization and outcome reports, such as the Health Plan 24
Employer Data and Information Set (HEDIS), as directed by the Department; and 25

3. At least semiannually, aggregate data that includes: 26

A. The number of enrollees provided with substance abuse 27
treatment services; and 28

B. The amount of money spent on substance abuse 29
treatment; 30

10 SENATE BILL 244

(iii) Promote timely access to and continuity of health care services 1
for enrollees; 2

(iv) Demonstrate organizational capacity to provide special 3
programs, including outreach, case management, and home visiting, tailored to meet the 4
individual needs of all enrollees; 5

(v) Provide assistance to enrollees in securing necessary health care 6
services; 7

(vi) Provide or assure alcohol and drug abuse treatment for 8
substance abusing pregnant women and all other enrollees of managed care organizations 9
who require these services; 10

(vii) Educate enrollees on health care prevention and good health 11
habits; 12

(viii) Assure necessary provider capacity in all geographic areas under 13
contract; 14

(ix) Be accountable and hold its subcontractors accountable for 15
standards established by the Department and, upon failure to meet those standards, be 16
subject to one or more of the following penalties: 17

1. Fines; 18

2. Suspension of further enrollments; 19

3. Withholding of all or part of the capitation payment; 20

4. Termination of the contract; 21

5. Disqualification from future participation in the Program; 22
and 23

6. Any other penalties that may be imposed by the 24
Department; 25

(x) Subject to applicable federal and State law, include incentives for 26
enrollees to comply with provisions of the managed care organization; 27

(xi) Provide or arrange to provide primary mental health services; 28

(xii) Provide or arrange to provide all Medicaid –covered services 29
required to comply with State statutes and regulations man dating health and mental 30
health services for children in State supervised care: 31

SENATE BILL 244 11

1. According to standards set by the Department; and 1

2. Locally, to the extent the services are available locally; 2

(xiii) Submit to the Department aggregate infor mation from the 3
quality assurance program, including complaints and resolutions from the enrollee and 4
provider grievance systems, the enrollee hotline, and enrollee satisfaction surveys; 5

(xiv) Maintain as part of the enrollee ’s medical record the follo wing 6
information: 7

1. The basic health risk assessment conducted on 8
enrollment; 9

2. Any information the managed care organization receives 10
that results from an assessment of the enrollee conducted for the purpose of any early 11
intervention, evaluation, planning, or case management program; 12

3. Information from the local department of social services 13
regarding any other service or benefit the enrollee receives, including assistance or benefits 14
from a program administered by the Department of Human Services under the Human 15
Services Article; and 16

4. Any information the managed care organization receives 17
from a school–based clinic, a core services agency, a local health department, or any other 18
person that has provided health services to the enrollee; 19

(xv) Upon provision of information specified by the Department 20
under paragraph (19) of this subsection, pay school –based clinics for services provided to 21
the managed care organization’s enrollees; 22

(xvi) In coordination with participating denti sts, enrollees, and 23
families of enrollees, develop a process to arrange to provide dental therapeutic treatment 24
to individuals under 21 years of age that requires: 25

1. A participating dentist to notify a managed care 26
organization when an enrollee is in need of therapeutic treatment and the dentist is unable 27
to provide the treatment; 28

2. A managed care organization to provide the enrollee or the 29
family of the enrollee with a list of participating providers who offer therapeutic dental 30
services; and 31

3. A managed care organization to notify the enrollee or the 32
family of the enrollee that the managed care organization will provide further assistance if 33
the enrollee has difficulty obtaining an appointment with a provider of therapeutic dental 34
services; 35
12 SENATE BILL 244

(xvii) Provide the advance directive information sheet developed under 1
§ 5–615 of this article: 2

1. To all enrollees at the time of initial enrollment and in the 3
managed care organization’s enrollee publications; 4

2. If the managed care organization maintains a website, on 5
the managed care organization’s website; and 6

3. At the request of an enrollee; and 7

(xviii) If a managed care organization maintains a website, after the tab 8
on the State –designated health information exchange websi te required under § 9
19–145(b)(2)(iv) of this article is developed, provide a link to the webpage that is accessed 10
through the tab. 11

(10) The Department shall adopt regulations that assure that managed care 12
organizations employ appropriate personnel to: 13

(i) Assure that individuals with special needs obtain needed 14
services; and 15

(ii) Coordinate those services. 16

(11) (i) A managed care organization shall reimburse a hospital 17
emergency facility and provider for: 18

1. Health care services that meet the definition of emergency 19
services in § 19–701 of this article; 20

2. Medical screening services rendered to meet the 21
requirements of the federal Emergency Medical Treatment and Active Labor Act; 22

3. Medically necessary services if the managed care 23
organization authorized, referred, or otherwise allowed the enrollee to use the emergency 24
facility and the medically necessary services are related to the condition for which the 25
enrollee was allowed to use the emergency facility; and 26

4. Medically necessary services that relate to the condition 27
presented and that are provided by the provider in the emergency facility to the enrollee if 28
the managed care organization fails to provide 24–hour access to a physician as required 29
by the Department. 30

(ii) A provider may not be required to obtain prior authorization or 31
approval for payment from a managed care organization in order to obtain reimbursement 32
under this paragraph. 33
SENATE BILL 244 13

(12) (i) Each managed care organization shall notify each enrollee when 1
the enrollee should obtain an immunization, examination, or other wellness service. 2

(ii) Each managed care organization shall: 3

1. Maintain evidence of compliance with paragraph (9) of 4
this subsection; and 5

2. Provide to the Department, upon initi al application to 6
provide health care services to enrollees and on an annual basis thereafter, evidence of 7
compliance with paragraph (9) of this subsection, including submission of a written plan. 8

(iii) A managed care organization that does not comply with 9
subparagraph (i) of this paragraph for at least 90% of its new enrollees: 10

1. Within 90 days of their enrollment may not receive more 11
than 80% of its capitation payments; 12

2. Within 180 days of their enrollment may not receive more 13
than 70% of its capitation payments; and 14

3. Within 270 days of their enrollment may not receive more 15
than 50% of its capitation payments. 16

(iv) If a managed care organization does not comply with the 17
requirements of paragraph (9) of this subsection, the Depar tment may contract with any 18
community–based health organization that the Department determines is willing and able 19
to perform comprehensive outreach services to enrollees. 20

(v) In addition to the provisions of subparagraph (iv) of this 21
paragraph, if a m anaged care organization does not comply with the requirements of 22
paragraph (9) of this subsection or fails to provide evidence of compliance to the Department 23
under subparagraph (ii) of this paragraph, the Department may: 24

1. Impose a fine on the mana ged care organization which 25
shall be deposited in the HealthChoice Performance Incentive Fund established under § 26
15–103.3 of this subtitle; 27

2. Suspend further enrollment into the managed care 28
organization; 29

3. Withhold all or part of the capitati on rate from the 30
managed care organization; 31

4. Terminate the provider agreement; or 32

14 SENATE BILL 244

5. Disqualify the managed care organization from future 1
participation in the Maryland Medicaid Managed Care Program. 2

(13) The Department shall: 3

(i) Establish and maintain an ombudsman program and a locally 4
accessible enrollee hotline; 5

(ii) Perform focused medical reviews of managed care organizations 6
that include reviews of how the managed care organizations are providing health care 7
services to special populations; 8

(iii) Provide timely feedback to each managed care organization on 9
its compliance with the Department’s quality and access system; 10

(iv) Establish and maintain within the Department a process for 11
handling provider complaints about managed care organizations; and 12

(v) Adopt regulations relating to appeals by managed care 13
organizations of penalties imposed by the Department, including regulations providing for 14
an appeal to the Office of Administrative Hearings. 15

(14) (i) Except as provided in subparagraph (iii) of this paragraph, the 16
Department shall delegate responsibility for maintaining the ombudsman program for a 17
county to that county ’s local health department on the request of the local health 18
department. 19

(ii) A local health department may not subcontract the ombudsman 20
program. 21

(iii) Before the Department delegates responsibility to a local health 22
department to maintain the ombudsman program for a county, a local health department 23
that is also a Medicaid provider must re ceive the approval of the Secretary and the local 24
governing body. 25

(15) A managed care organization may not: 26

(i) Without authorization by the Department, enroll an individual 27
who at the time is a Program recipient; or 28

(ii) Have face–to–face or telephone contact, or otherwise solicit with 29
an individual who at the time is a Program recipient before the Program recipient enrolls 30
in the managed care organization unless: 31

1. Authorized by the Department; or 32

2. The Program recipient initiates contact. 33
SENATE BILL 244 15

(16) (i) The Department shall be responsible for enrolling Program 1
recipients into managed care organizations. 2

(ii) The Department may contract with an entity to perform the 3
enrollment function. 4

(iii) The Department or its enrollment con tractor shall administer a 5
health risk assessment developed by the Department to ensure that individuals who need 6
special or immediate health care services will receive the services on a timely basis. 7

(iv) The Department or its enrollment contractor: 8

1. May administer the health risk assessment only after the 9
Program recipient has chosen a managed care organization; and 10

2. Shall forward the results of the health risk assessment to 11
the managed care organization chosen by the Program recipient within 5 business days. 12

(17) For a managed care organization with which the Secretary contracts to 13
provide services to Program recipients under this subsection, the Secretary shall establish 14
a mechanism to initially assure that each historic provider tha t meets the Department ’s 15
quality standards has the opportunity to continue to serve Program recipients as a 16
subcontractor of at least one managed care organization. 17

(18) (i) The Department shall make capitation payments to each 18
managed care organization as provided in this paragraph. 19

(ii) In consultation with the Insurance Commissioner, the Secretary 20
shall: 21

1. Set capitation payments at a level that is actuarially 22
adjusted to the benefits provided; and 23

2. Actuarially adjust the capitation p ayments to reflect the 24
relative risk assumed by the managed care organization. 25

(iii) In actuarially adjusting capitation payments under 26
subparagraph (ii)2 of this paragraph, the Secretary, in consultation with the Insurance 27
Commissioner, shall take int o account, to the extent allowed under federal law, the 28
expenses incurred by the managed care organization applicable to the business of providing 29
care to enrolled individuals. 30

(19) (i) School–based clinics and managed care organizations shall 31
collaborate to provide continuity of care to enrollees. 32

16 SENATE BILL 244

(ii) School–based clinics shall be defined by the Department in 1
consultation with the State Department of Education. 2

(iii) Each managed care organization shall require a school –based 3
clinic to provide to the managed care organization certain information, as specified by the 4
Department, about an encounter with an enrollee of the managed care organization prior 5
to paying the school–based clinic. 6

(iv) Upon receipt of information specified by the Depart ment, the 7
managed care organization shall pay, at Medicaid –established rates, school–based clinics 8
for covered services provided to enrollees of the managed care organization. 9

(v) The Department shall work with managed care organizations 10
and school–based clinics to develop collaboration standards, guidelines, and a process to 11
assure that the services provided are covered and medically appropriate and that the 12
process provides for timely notification among the parties. 13

(vi) Each managed care organiza tion shall maintain records of all 14
health care services: 15

1. Provided to its enrollees by school–based clinics; and 16

2. For which the managed care organization has been billed. 17

(20) The Department shall establish standards for the timely delivery of 18
services to enrollees. 19

(21) (i) The Department shall establish a delivery system for specialty 20
mental health services for enrollees of managed care organizations. 21

(ii) The Behavioral Health Administration shall: 22

1. Design and monitor the delivery system; 23

2. Establish performance standards for providers in the 24
delivery system; and 25

3. Establish procedures to ensure appropriate and timely 26
referrals from managed care organizations to the delivery system that include: 27

A. Specification of the diagnoses and conditions eligible for 28
referral to the delivery system; 29

B. Training and clinical guidance in appropriate use of the 30
delivery system for managed care organization primary care providers; 31

SENATE BILL 244 17

C. Preauthorization by the utilization review agent of the 1
delivery system; and 2

D. Penalties for a pattern of improper referrals. 3

(iii) The Department shall collaborate with managed care 4
organizations to develop standards and guidelines for the provision of specialty menta l 5
health services. 6

(iv) The delivery system shall: 7

1. Provide all specialty mental health services needed by 8
enrollees; 9

2. For enrollees who are dually diagnosed, coordinate the 10
provision of substance use disorder services provided by the managed care organizations of 11
the enrollees; 12

3. Consist of a network of qualified mental health 13
professionals from all core disciplines; 14

4. Include linkages with other public service systems; and 15

5. Comply with quality assurance, enrollee in put, data 16
collection, and other requirements specified by the Department in regulation. 17

(v) The Department may contract with a managed care organization 18
for delivery of specialty mental health services if the managed care organization meets the 19
performance standards adopted by the Department in regulations. 20

(vi) The provisions of § 15–1005 of the Insurance Article apply to the 21
delivery system for specialty mental health services established under this paragraph and 22
administered by an administrative services organization. 23

(vii) The Department and the Behavioral Health Administration 24
shall ensure that the delivery system has an adequate network of providers available to 25
provide substance use disorder treatment for children under the age of 18 years. 26

(22) The Department shall include a definition of medical necessity in its 27
quality and access standards. 28

(23) (i) The Department shall adopt regulations relating to enrollment, 29
disenrollment, and enrollee appeals. 30

(ii) Program recipients shall have the right to choose: 31

18 SENATE BILL 244

1. The managed care organization with which they are 1
enrolled; and 2

2. The primary care provider to whom they are assigned 3
within the managed care organization. 4

(iii) If a recipient is disenrolled and reenrolls within 120 days of the 5
recipient’s disenrollment, the Department shall: 6

1. Assign the recipient to the managed care organization in 7
which the recipient previously was enrolled; and 8

2. Require the managed care organization to assign the 9
recipient to the primary care provider of record at the time of the recipient’s disenrollment. 10

(iv) Whenever a recipient has to select a new managed care 11
organization because the recipient ’s managed care organization has departed from the 12
HealthChoice Program, the departing managed care organization: 13

1. Shall provide a written notice to the recipient 60 days 14
before departing from the Program; 15

2. Shall include in the notice the name and provider number 16
of the primary care provider assigned to the recipient and the telephone number of the 17
enrollment broker; and 18

3. Within 30 days after departing from the Program, shall 19
provide the Department with a list of enrollees and the name of each enrollee ’s primary 20
care provider. 21

(v) On receiving the list provided by the managed care organization, 22
the Department shall provide the list to: 23

1. The enrollment broker to assist and provide outreach to 24
recipients in selecting a managed care organization; and 25

2. The remaining managed care organizations for the 26
purpose of linking recipients with a primary care provider in accordance with federal law 27
and regulation. 28

(vi) Subject to subsection (f)(4) and (5) of this section, an enrollee may 29
disenroll from a managed care organization: 30

1. Without cause in the month following the anniversary 31
date of the enrollee’s enrollment; and 32

2. For cause, at any time as determined by the Secretary. 33
SENATE BILL 244 19

(24) The Department or its subcontractor, to the extent feasible in its 1
marketing or enrollment programs, shall hire individuals receiving assistance under the 2
program of Aid to Families with Dependent Children established under Title IV, Part A, of 3
the Social Security Act, or the successor to the program. 4

(25) The Department shall disenroll an enrollee who is a child in 5
State–supervised care if the child is transferred to an area outside of the territory of the 6
managed care organization. 7

(26) The Secretary shall adopt regulations to implement the provisions of 8
this section. 9

(27) (i) 1. The Department shall esta blish the Maryland Medicaid 10
Advisory Committee, composed of no more than 25 members. 11

2. The majority of the members of the Committee shall be 12
enrollees or enrollee advocates. 13

3. At least five members of the Committee shall be enrollees 14
representative of the entire Medicaid population. 15

(ii) The Committee members shall include: 16

1. At least five current or former enrollees or the parents or 17
guardians of current or former enrollees; 18

2. Providers who are familiar with the medical needs of 19
low–income population groups, including board–certified physicians; 20

3. Hospital representatives; 21

4. At least five but not more than 10 advocates for the 22
Medicaid population, including representatives of special needs populations, such as: 23

A. Children with special needs; 24

B. Individuals with physical disabilities; 25

C. Individuals with developmental disabilities; 26

D. Individuals with mental illness; 27

E. Individuals with brain injuries; 28

F. Medicaid and Medicare dual eligibles; 29

20 SENATE BILL 244

G. Individuals who are homeless or have experienced 1
homelessness; 2

H. Individuals enrolled in home – and community –based 3
services waivers; 4

I. Elderly individuals; 5

J. Low–income individuals and individuals receiving 6
benefits through the Temporary Assistance for Needy Families Program; and 7

K. Individuals receiving substance abuse treatment services; 8

5. Two members of the Finance Committee of the Senate of 9
Maryland, appointed by the President of the Senate; and 10

6. Three members of the Maryland House of Delegates, 11
appointed by the Speaker of the House. 12

(iii) A designee of each of the following shall serve as an ex –officio 13
member of the Committee: 14

1. The Secretary of Human Services; 15

2. The Executive Direct or of the Maryland Health Care 16
Commission; and 17

3. The Maryland Association of County Health Officers. 18

(iv) In addition to any duties imposed by federal law and regulation, 19
the Committee shall: 20

1. Advise the Secretary on the implementation, operation, 21
and evaluation of managed care programs under this section; 22

2. Review and make recommendations on the regulations 23
developed to implement managed care programs under this section; 24

3. Review and make recommendations on the standards used 25
in contracts between the Department and managed care organizations; 26

4. Review and make recommendations on the Department ’s 27
oversight of quality assurance standards; 28

5. Review data collected by the Department from managed 29
care organizations participating in the Program and data collected by the Maryland Health 30
Care Commission; 31
SENATE BILL 244 21

6. Promote the dissemination of managed care organization 1
performance information, including loss ratios, to enrollees in a manner that facilitates 2
quality comparisons and uses layman’s language; 3

7. Assist the Department in evaluating the enrollment 4
process; and 5

8. Review reports of the ombudsmen. 6

(v) Except as specified in subparagraphs (ii) and (iii) of this 7
paragraph, the members of the Maryland Medicaid Advisory Committee shall be appointed 8
by the Secretary and serve for a 4–year term. 9

(vi) In making appointments to the Committee, the Secretary shall 10
provide for continuity and rotation. 11

(vii) In appointing consumer members to the Committee, the 12
Secretary shall seek recommendations from: 13

1. The State Protection and Advocacy System Organization; 14

2. The Statewide Independent Living Council; 15

3. The Developmental Disabilities Council; 16

4. The Department of Disabilities; 17

5. The Department of Aging; 18

6. Consumer advocacy organizations; and 19

7. The public. 20

(viii) The Secretary shall appoint the chair of the Committee. 21

(ix) The Secretary shall appoint nonvoting members from managed 22
care organizations who may particip ate in Committee meetings, unless the Committee 23
meets in closed session as provided in § 3–305 of the General Provisions Article. 24

(x) The Department shall provide staff for the Committee. 25

(xi) The Committee shall determine the times and places of i ts 26
meetings. 27

(xii) 1. The chair of the Committee and the staff for the 28
Committee shall provide the agenda, minutes, and any written materials to be presented 29
22 SENATE BILL 244

or discussed at a meeting to the members of the Committee at least 5 days prior to the 1
meeting. 2

2. The agenda, minutes, and written materials shall be 3
provided to members of the Committee in a manner and format that reasonably 4
accommodates the specific needs of the member. 5

(xiii) 1. Except as provided in subsubparagraph 2 of this 6
subparagraph, a member of the Committee: 7

A. May not receive compensation; but 8

B. Is entitled to reimbursement for expenses under the 9
Standard State Travel Regulations, as provided in the State budget. 10

2. A member of the Committee who is an enrollee is entitled 11
to reimbursement for: 12

A. Expenses for personal and dependent care incurred during 13
the meeting and during travel time to and from the meeting; 14

B. Expenses for cognitive supports related to the meeting; 15
and 16

C. Appropriate transportation to and from the meeting. 17

3. On request, the Department shall provide for a dedicated 18
Department staff person: 19

A. To review meeting materials with enrollee members in 20
advance of a meeting by telephone or in person; and 21

B. To provide referrals to advocacy organizations.] 22

[(28) (i)] (F) (1) The Department shall ensure that payments for 23
services provided by a hospital located in a contiguous state or in the District of Columbia 24
to an enrollee under the Program shall be reduced by 20% if the hospital fails to submit 25
discharge data on all Maryland patients receiving care in the hospital to the Health 26
Services Cost Review Commission in a form and manner the Commission specifies. 27

[(ii)] (2) [Subparagraph (i) of this paragraph] PARAGRAPH (1) OF 28
THIS SUBSECTION does not apply to a hospital that presently provides discharge data to 29
the public in a form the Health Services Cost Review Commission determines is 30
satisfactory. 31

[(29) A managed care organization shall provide coverage for hearing loss 32
screenings of newborns provided by a hospital before discharge. 33
SENATE BILL 244 23

(30) (i) The Department shall provide enrollees and health care 1
providers with an accurate directory or other listing of all available providers: 2

1. In written form, made available upon request; and 3

2. On an Internet database. 4

(ii) The Department shall update the Internet database at least 5
every 30 days. 6

(iii) The written directory shall include a conspicuous reference to the 7
Internet database. 8

(31) Paragraph (9)(xvii) of this subsection may not be construed to require a 9
managed care organization to: 10

(i) Assist an enrollee in drafting an electronic advance care 11
planning document; 12

(ii) Store electronic advance care planning documents; or 13

(iii) Access advance care planning documents. 14

(32) A managed care organization may not apply a prior authorization 15
requirement for a prescription drug used as postexposure prophylaxis for the prevention of 16
HIV if the prescription drug is prescribed for use in accor dance with Centers for Disease 17
Control and Prevention guidelines. 18

(33) The Secretary shall adopt regulations for pharmacy benefits managers 19
that contract with managed care organizations that establish requirements for conducting 20
audits of pharmacies or pharmacists that are: 21

(i) To the extent practicable, substantively similar to the audit 22
provisions under § 15–1629 of the Insurance Article; and 23

(ii) Consistent with federal law.] 24

[(c)] (G) (1) (i) In this subsection the following words have the meanings 25
indicated. 26

(ii) “Certified nurse practitioner ” means a registered nurse who is 27
licensed in this State, has completed a nurse practitioner program approved by the State 28
Board of Nursing, and has passed an examination approved by that Board. 29

(iii) “Nurse anesthetist” means a registered nurse who is: 30

24 SENATE BILL 244

1. Certified under the Health Occupations Article to practice 1
nurse anesthesia; and 2

2. Certified by the Council on Certification or the Council on 3
Recertification of Nurse Anesthetists. 4

(iv) “Nurse midwife” means a registered nurse who is licensed in this 5
State and has been certified by the American College of Nurse –Midwives as a nurse 6
midwife. 7

(v) “Optometrist” has the meaning stated in § 11–101 of the Health 8
Occupations Article. 9

(2) The Secretary may contract for the provision of care under the Program 10
to eligible Program recipients. 11

(3) The Secretary may contract with insurance companies or nonprofit 12
health service plans or with individuals, associations, partnerships, inc orporated or 13
unincorporated groups of physicians, chiropractors, dentists, podiatrists, optometrists, 14
pharmacists, hospitals, nursing homes, nurses, including nurse anesthetists, nurse 15
midwives and certified nurse practitioners, opticians, and other health practitioners who 16
are licensed or certified in this State and perform services on the prescription or referral of 17
a physician. 18

(4) For the purposes of this section, the nurse midwife need not be under 19
the supervision of a physician. 20

(5) Except as ot herwise provided by law, a contract that the Secretary 21
makes under this subsection shall continue unless terminated under the terms of the 22
contract by the Program or by the provider. 23

[(d)] (H) As permitted by federal law or waiver, the Secretary may admi nister 24
the Medicare Option Prescription Drug Program, established under § 15–124.3 of this 25
subtitle, as part of the Maryland Medical Assistance Program. 26

[(e)] (I) By regulation, the Department shall adopt a methodology to ensure 27
that federally qualified health centers are paid reasonable cost–based reimbursement that 28
is consistent with federal law. 29

[(f) (1) The Department shall establish mechanisms for: 30

(i) Identifying a Program recipient ’s primary care provider at the 31
time of enrollment into a managed care program; and 32

(ii) Maintaining continuity of care with the primary care provider if: 33

SENATE BILL 244 25

1. The provider has a contract with a managed care 1
organization or a contracted medical group of a managed care organization to provide 2
primary care services; and 3

2. The recipient desires to continue care with the provider. 4

(2) If a Program recipient enrolls in a managed care organization and 5
requests assignment to a particular primary care provider who has a contract with the 6
managed care orga nization or a contracted group of the managed care organization, the 7
managed care organization shall assign the recipient to the primary care provider. 8

(3) A Program recipient may request a change of primary care providers 9
within the same managed care o rganization at any time and, if the primary care provider 10
has a contract with the managed care organization or a contracted group of the managed 11
care organization, the managed care organization shall honor the request. 12

(4) In accordance with the federal Health Care Financing Administration’s 13
guidelines, a Program recipient may elect to disenroll from a managed care organization if 14
the managed care organization terminates its contract with the Department. 15

(5) A Program recipient may disenroll from a ma naged care organization 16
to maintain continuity of care with a primary care provider if: 17

(i) The contract between the primary care provider and the 18
managed care organization or contracted group of the managed care organization 19
terminates because: 20

1. The managed care organization or contracted group of the 21
managed care organization terminates the provider ’s contract for a reason other than 22
quality of care or the provider’s failure to comply with contractual requirements related to 23
quality assurance activities; 24

2. A. The managed care organization or contracted group 25
of the managed care organization reduces the primary care provider ’s capitated or 26
applicable fee for services rates; 27

B. The reduction in rates is greater than the actual change in 28
rates or capitation paid to the managed care organization by the Department; and 29

C. The provider and the managed care organization or 30
contracted group of the managed care organization are unable to negotiate a mutually 31
acceptable rate; or 32

3. The provider contract between the provider and the 33
managed care organization is terminated because the managed care organization is 34
acquired by another entity; and 35

26 SENATE BILL 244

(ii) 1. The Program recipient desires to continue to receive care 1
from the primary care provider; 2

2. The provider contracts with at least one other managed 3
care organization or contracted group of a managed care organization; and 4

3. The enrollee notifies the Department or the Department’s 5
designee of the enrollee’s intention within 90 days after the contract termination. 6

(6) The Department shall provide timely notification to the affected 7
managed care organization of an enrollee ’s intention to disenroll under the provisions of 8
paragraph (5) of this subsection.] 9

15–103.1. 10

(A) AS PER MITTED BY FEDERAL LA W OR WAIVER , THE SECRETARY MAY 11
ESTABLISH A PROGRAM UNDER WHICH PROGRAM RECIPIENTS AR E REQUIRED TO 12
ENROLL IN MANAGED CARE ORGANIZATIONS. 13

(B) (1) THE BENEFITS REQUIRED BY THE PROGRAM DEVELOPED UNDER 14
SUBSECTION (A) OF THIS SECTION SHALL BE: 15

(I) ADOPTED BY REGULATION; AND 16

(II) AT LEAST EQUIVALENT T O THE BENEFIT LEVEL REQUIRED 17
BY THE PROGRAM ON JANUARY 1, 1996. 18

(2) SUBJECT TO THE LIMITA TIONS OF THE STATE BUDGET AND AS 19
PERMITTED BY FEDERAL LAW OR WAIVER , THE DEPARTMENT SHALL PROV IDE 20
REIMBURSEMENT FOR MED ICALLY NECESSARY AND APPROPRIATE INPATIEN T, 21
INTERMEDIATE CARE , AND HALFWAY HOUSE SU BSTANCE USE DISORDER 22
TREATMENT SERVICES FOR ENROLLEES AT LEAST 21 YEARS OLD WITH SUBSTANCE 23
USE DISORDERS WHO AR E RECIPIENTS OF TEMP ORARY CASH ASSISTANC E UNDER 24
THE FAMILY INVESTMENT PROGRAM. 25

(3) EACH MANAGED CARE ORG ANIZATION PARTICIPAT ING IN THE 26
PROGRAM DEVELOPED UNDER SUBSECTION (A) OF THIS SECTION SHAL L PROVIDE 27
OR ARRANGE FOR THE PROVISION OF THE BENEFITS DESCRIBED IN PARAGRAPH (2) 28
OF THIS SUBSECTION. 29

(4) THIS SUBSECTION MAY N OT BE CONSTRUED TO P ROHIBIT A 30
MANAGED CARE ORGANIZ ATION FROM OFFERING ADDITIONAL BENEFITS IF THE 31
MANAGED CARE ORGANIZATION IS NOT RECEIVI NG CAPITATION PAYMENTS BASED 32
ON THE PROVISION OF THE ADDITIONAL BENEFITS. 33
SENATE BILL 244 27

(5) NOTWITHSTANDING PARAGRAPH (1) OF THIS SUBSECTION , THE 1
BENEFITS REQUIRED BY THE PROGRAM DEVELOPE D UNDER SUBSECTION (A) OF 2
THIS SECTION SHALL INCLUDE DENTAL SERVICES FOR PREGNANT WOMEN. 3

(C) SUBJECT TO THE LIMITA TIONS OF THE STATE BUDGET AND AS 4
PERMITTED BY FEDERAL LAW OR WAIVER , THE PROGRAM DEVELOPE D UNDER 5
SUBSECTION (A) OF THIS SECTION MAY PROVIDE GUARANTEED E LIGIBILITY FOR 6
EACH ENROLLEE FOR UP TO 6 MONTHS UNLESS AN ENR OLLEE OBTAINS HEALTH 7
INSURANCE THROUGH ANOTHER SOURCE. 8

(D) (1) THE SECRETARY MAY EXCLUDE SPECIFIC POPULATIONS OR 9
SERVICES FROM THE PR OGRAM DEVELOPED UNDE R SUBSECTION (A) OF THIS 10
SECTION. 11

(2) FOR ANY POPULATIONS O R SERVICES EXCLUDED UNDER THIS 12
SUBSECTION, THE SECRETARY MAY AUTHORIZE A MANAGED CARE OR GANIZATION 13
TO PROVIDE THE SERVI CES OR PROVIDE FO R THE POPULATION , INCLUDING 14
AUTHORIZATION OF A S EPARATE DENTAL MANAG ED CARE ORGANIZATION OR A 15
MANAGED CARE ORGANIZATION TO PROVIDE SER VICES TO PROGRAM RECIPIENTS 16
WITH SPECIAL NEEDS. 17

(E) (1) EXCEPT FOR A SERVICE EXCLUDED BY THE SECRETARY UNDER 18
SUBSECTION (D) OF THIS SECTION , EACH MANAGED CARE OR GANIZATION SHALL 19
PROVIDE ALL THE BENE FITS REQUIRED BY REG ULATIONS ADOPTED UND ER 20
SUBSECTION (B) OF THIS SECTION. 21

(2) FOR A POPULATION OR S ERVICE EXCLUDED BY T HE SECRETARY 22
UNDER SUBSECTION (D) OF THIS SECTION , THE SECRETARY MAY AUTHORI ZE A 23
MANAGED CARE ORGANIZ ATION TO PROVIDE ONL Y FOR THAT POPULATIO N OR 24
PROVIDE ONLY THAT SERVICE. 25

(3) A MANAGED CARE ORGANIZATION MAY SUBCONTRACT SPECIFIED 26
REQUIRED SERVICES TO A HEALTH CARE PROVID ER THAT IS LICENSED OR 27
AUTHORIZED TO PROVIDE THOSE SERVICES. 28

(F) EXCEPT FOR THE PROGRAM OF ALL–INCLUSIVE CARE FOR THE 29
ELDERLY (“PACE”) PROGRAM, THE SECRETARY MAY NOT INC LUDE THE 30
LONG–TERM CARE POPULATION OR LONG–TERM CARE SERVICES IN THE PROGRAM 31
DEVELOPED UNDER SUBSECTION (A) OF THIS SECTION. 32

(G) THE PROGRAM DEVELOPED UNDER SUBSECTION (A) OF THIS SECTION 33
SHALL ENSURE THAT ENROLLEES HAVE ACCESS TO A PHARMACY THAT: 34
28 SENATE BILL 244

(1) IS LICENSED IN THE STATE; AND 1

(2) IS WITHIN A REASONABL E DISTANCE FROM THE ENROLLEE’S 2
RESIDENCE. 3

(H) FOR CAUSE , THE DEPARTMENT MAY DISENR OLL ENROLLEES FROM A 4
MANAGED CARE ORGANIZ ATION AND ENROLL THE M IN ANOTHER MANAGED CARE 5
ORGANIZATION. 6

(I) (1) EACH MANAGED CARE ORGANIZATION SHALL: 7

(I) HAVE A QUALITY ASSURANCE PROGRAM IN EFFECT THAT IS 8
SUBJECT TO THE APPROVAL OF THE DEPARTMENT AND THAT, AT A MINIMUM: 9

1. COMPLIES WITH ANY HEA LTH CARE QUALITY 10
IMPROVEMENT SYSTEM D EVELOPED BY THE CENTERS FOR MEDICARE AND 11
MEDICAID SERVICES; 12

2. COMPLIES WITH THE QUA LITY REQUIREMENTS OF 13
APPLICABLE STATE LICENSURE LAWS AND REGULATIONS; 14

3. COMPLIES WITH PRACTIC E GUIDELINES AND 15
PROTOCOLS SPECIFIED BY THE DEPARTMENT; 16

4. PROVIDES FOR AN ENROL LEE GRIEVANCE SYSTEM , 17
INCLUDING AN ENROLLEE HOTLINE; 18

5. PROVIDES FOR A PROVIDER GRIEVANCE SYSTEM; 19

6. PROVIDES FOR ENROL LEE AND PROVIDER 20
SATISFACTION SURVEYS, TO BE TAKEN AT LEAST ANNUALLY; 21

7. PROVIDES FOR A CONSUM ER ADVISORY BOARD TO 22
RECEIVE REGULAR INPUT FROM ENROLLEES; 23

8. PROVIDES FOR AN ANNUA L CONSUMER ADVISORY 24
BOARD REPORT TO BE SUBMITTED TO THE SECRETARY; AND 25

9. COMPLIES WITH SPECIFI C QUALITY , ACCESS, DATA, 26
AND PERFORMANCE MEAS UREMENTS ADOPTED BY THE DEPARTMENT FOR 27
TREATING ENROLLEES WITH SPECIAL NEEDS; 28

SENATE BILL 244 29

(II) SUBMIT TO THE DEPARTMENT: 1

1. SERVICE–SPECIFIC DATA BY SER VICE TYPE IN A 2
FORMAT ESTABLISHED BY THE DEPARTMENT; 3

2. UTILIZATION AND OUTCOME REPORTS, SUCH AS THE 4
HEALTH PLAN EMPLOYER DATA AND INFORMATION SET (HEDIS), AS DIRECTED 5
BY THE DEPARTMENT; AND 6

3. AT LEAST SEMIANNUALLY , AGGREGATE DATA THAT 7
INCLUDES: 8

A. THE NUMBER OF ENROLLE ES PROVIDED WITH 9
SUBSTANCE USE DISORDER TREATMENT SERVICES; AND 10

B. THE AMOUNT OF MONEY S PENT ON SUBSTANCE US E 11
DISORDER TREATMENT; 12

(III) PROMOTE TIMELY ACCESS TO AND CONTINUITY OF HEALTH 13
CARE SERVICES FOR ENROLLEES; 14

(IV) DEMONSTRATE ORGANIZATIONAL CAPAC ITY TO PROVIDE 15
SPECIAL PROGRAMS , INCLUDING OUTREACH , CASE MANAGEMENT , AND HOME 16
VISITING, TAILORED TO MEET THE INDIVIDUAL NEEDS OF ALL ENROLLEES; 17

(V) PROVIDE ASSISTANCE TO ENROLLEES IN SECURIN G 18
NECESSARY HEALTH CARE SERVICES; 19

(VI) PROVIDE OR ENSURE SUB STANCE USE DISORDER 20
TREATMENT FOR PREGNA NT WOMEN WITH SUBSTA NCE USE DISORDERS AN D ALL 21
OTHER ENROLLEES OF T HE MANAGED CARE ORGA NIZATION WHO REQUIRE THESE 22
SERVICES; 23

(VII) EDUCATE ENROLLEES ON HEALTH CARE PREVENTION AND 24
GOOD HEALTH HABITS; 25

(VIII) ENSURE NECESSARY PROV IDER CAPACITY IN ALL 26
GEOGRAPHIC AREAS UNDER CONTRACT; 27

(IX) BE ACCOUNTABLE AND HO LD ITS SUBCONTRACTOR S 28
ACCOUNTABLE FOR STAN DARDS ESTABLISHED BY THE DEPARTMENT AND , ON 29
FAILURE TO MEET THOS E STANDARDS , BE SUBJECT TO ONE OR MORE OF THE 30
FOLLOWING PENALTIES: 31
30 SENATE BILL 244

1. FINES; 1

2. SUSPENSION OF FURTHER ENROLLMENTS; 2

3. WITHHOLDING OF ALL OR PART OF THE CAPITATION 3
PAYMENT; 4

4. TERMINATION OF THE CONTRACT; 5

5. DISQUALIFICATION FROM FUTURE PARTICIPATION IN 6
THE PROGRAM; AND 7

6. ANY OTHER PENALTIES T HAT MAY BE IMPOSED B Y 8
THE DEPARTMENT; 9

(X) SUBJECT TO APPLICABLE FEDERAL AND STATE LAW , 10
INCLUDE INCENTIVES F OR ENROLLEES TO COMP LY WITH PROVISIONS O F THE 11
MANAGED CARE ORGANIZATION; 12

(XI) PROVIDE OR ARRANGE TO PROVIDE PRIMARY MENT AL 13
HEALTH SERVICES; 14

(XII) PROVIDE OR ARRANGE TO PROVIDE ALL 15
MEDICAID–COVERED SERVICES REQUIRED TO COMPLY WITH STATE STATUTES AND 16
REGULATIONS MANDATING HEALTH AND MENTAL HEALTH SERVICES FOR CHILDREN 17
IN STATE–SUPERVISED CARE: 18

1. ACCORDING TO STANDARD S SET BY THE 19
DEPARTMENT; AND 20

2. LOCALLY, TO THE EXTENT THE SE RVICES ARE 21
AVAILABLE LOCALLY; 22

(XIII) SUBMIT TO THE DEPARTMENT AGGREGATE INFORMATION 23
FROM THE QUALITY ASS URANCE PROGRAM , INCLUDING COMPLAINTS AND 24
RESOLUTIONS FROM T HE ENROLLEE AND PROV IDER GRIEVANCE SYSTE MS, THE 25
ENROLLEE HOTLINE, AND ENROLLEE SATISFACTION SURVEYS; 26

(XIV) MAINTAIN AS PART OF THE ENROLLEE’S MEDICAL RECORD 27
THE FOLLOWING INFORMATION: 28

SENATE BILL 244 31

1. THE BASIC HEALTH RISK ASSESSMENT CONDUCTED 1
ON ENROLLMENT; 2

2. ANY INFORMATION THE M ANAGED CARE 3
ORGANIZATION RECEIVES THAT RESULTS FROM AN ASSESSMENT OF THE ENROLLEE 4
CONDUCTED FOR THE PU RPOSE OF ANY EARLY I NTERVENTION, EVALUATION, 5
PLANNING, OR CASE MANAGEMENT PROGRAM; 6

3. INFORMATION FROM THE LOCAL DEPARTMEN T OF 7
SOCIAL SERVICES REGA RDING ANY OTHER SERV ICE OR BENEFIT THE E NROLLEE 8
RECEIVES, INCLUDING ASSISTANCE OR BENEFITS FROM A PROGRAM ADMINISTERED 9
BY THE DEPARTMENT OF HUMAN SERVICES UNDER THE HUMAN SERVICES 10
ARTICLE; AND 11

4. ANY INFORMATION THE M ANAGED CA RE 12
ORGANIZATION RECEIVE S FROM A SCHOOL –BASED CLINIC , A CORE SERVICES 13
AGENCY, A LOCAL HEALTH DEPAR TMENT, OR ANY OTHER PERSON THAT HAS 14
PROVIDED HEALTH SERVICES TO THE ENROLLEE; 15

(XV) ON PROVISION OF INFOR MATION SPECIFIED BY THE 16
DEPARTMENT UNDER SUBS ECTION (R)(3) OF THIS SECTION , PAY SCHOOL –BASED 17
CLINICS FOR SERVICES PROVIDED TO THE MANA GED CARE ORGANIZATIO N’S 18
ENROLLEES; 19

(XVI) IN COORDINATION WITH PARTICIPATING DENTIS TS, 20
ENROLLEES, AND FAMILIES OF ENRO LLEES, DEVELOP A PROCESS TO ARRANGE TO 21
PROVIDE DENTAL THERAPEUTIC TREATMENT TO INDIVIDUALS UNDER THE AGE OF 22
21 YEARS THAT REQUIRES: 23

1. A PARTICIPATING DENTIS T TO NOTIFY A MANAGE D 24
CARE ORGANIZATION WH EN AN ENROLLEE IS IN NEED OF THERAPEUTIC 25
TREATMENT AND THE DENTIST IS UNABLE TO PROVIDE THE TREATMENT; 26

2. THE MANAGED CARE ORGA NIZATION TO PROVIDE 27
THE ENROLLEE OR THE FAMILY OF THE ENROLLEE WITH A LIST OF PARTICIPATING 28
PROVIDERS WHO OFFER THERAPEUTIC DENTAL SERVICES; AND 29

3. THE MANAGED CARE ORGA NIZATION TO NOTIFY T HE 30
ENROLLEE OR THE FAMI LY OF THE E NROLLEE THAT THE MAN AGED CARE 31
ORGANIZATION WILL PR OVIDE FURTHER ASSIST ANCE IF THE ENROLLEE HAS 32
DIFFICULTY OBTAINING AN APPOINTMENT WITH A PROVIDER OF THERAP EUTIC 33
DENTAL SERVICES; 34

32 SENATE BILL 244

(XVII) PROVIDE THE ADVANCE D IRECTIVE INFORMATION SHEET 1
DEVELOPED UNDER § 5–615 OF THIS ARTICLE: 2

1. TO ALL ENROLLEES AT T HE TIME OF INITIAL 3
ENROLLMENT AND IN TH E MANAGED CARE ORGAN IZATION’S ENROLLEE 4
PUBLICATIONS; 5

2. IF THE MANAGED CARE O RGANIZATION MAINTAINS A 6
WEBSITE, ON THE MANAGED CARE ORGANIZATION’S WEBSITE; AND 7

3. AT THE REQUEST OF AN ENROLLEE; AND 8

(XVIII) IF THE MANAGED CARE O RGANIZATION MAINTAINS A 9
WEBSITE, PROVIDE A LINK TO THE WEBPAGE THAT IS ACCESSED THROUGH THE TAB 10
ON THE STATE–DESIGNATED HEALTH IN FORMATION EXCHANGE W EBSITE 11
REQUIRED UNDER § 19–145.1(B)(2)(IV) OF THIS ARTICLE. 12

(2) PARAGRAPH (1)(XVII) OF THIS SUBSECTION M AY NOT BE 13
CONSTRUED TO REQUIRE A MANAGED CARE ORGANIZATION TO: 14

(I) ASSIST AN ENROLLEE IN DRAFTING AN ELECTRON IC 15
ADVANCE CARE PLANNING DOCUMENT; 16

(II) STORE ELECTRONIC ADVA NCE CARE PLANNING 17
DOCUMENTS; OR 18

(III) ACCESS ADVANCE CARE PLANNING DOCUMENTS. 19

(3) (I) EACH MANAGED CARE ORGANIZATION SHALL NOTIFY EACH 20
ENROLLEE WHEN THE EN ROLLEE SHOULD OBTAIN AN IMMUNIZATION , 21
EXAMINATION, OR OTHER WELLNESS SERVICE. 22

(II) EACH MANAGED CARE ORGANIZATION SHALL: 23

1. MAINTAIN EVIDENCE OF COMPLIANCE WITH 24
PARAGRAPH (1) OF THIS SUBSECTION; AND 25

2. ON INITIAL APPLICATION TO PROVIDE HEALTH CARE 26
SERVICES TO ENROLLEES AND ON AN ANNUAL BASIS THEREAFTER, PROVIDE TO THE 27
DEPARTMENT EVI DENCE OF COMPLIANCE WITH PARAGRAPH (1) OF THIS 28
SUBSECTION INCLUDING SUBMISSION OF A WRITTEN PLAN. 29

SENATE BILL 244 33

(III) A MANAGED CARE ORGANIZATION THAT DOES NOT COMPLY 1
WITH PARAGRAPH (1) OF THIS SUBSECTION F OR AT LEAST 90% OF ITS NEW 2
ENROLLEES: 3

1. WITHIN 90 DAYS OF THEIR ENROLLMENT MAY NOT 4
RECEIVE MORE THAN 80% OF ITS CAPITATION PAYMENTS; 5

2. WITHIN 180 DAYS OF THEIR ENROLL MENT MAY NOT 6
RECEIVE MORE THAN 70% OF ITS CAPITATION PAYMENTS; AND 7

3. WITHIN 270 DAYS OF THEIR ENROLL MENT MAY NOT 8
RECEIVE MORE THAN 50% OF ITS CAPITATION PAYMENTS. 9

(IV) IF A MANAGED CARE ORG ANIZATION DOES NOT C OMPLY 10
WITH THE REQUIREMENT S OF PARAGRAPH (1) OF THIS SUBSECTION , THE 11
DEPARTMENT MAY CONTRA CT WITH ANY COMMUNIT Y–BASED HEALTH 12
ORGANIZATION THAT TH E DEPARTMENT DETERMINES IS WIL LING AND ABLE TO 13
PERFORM COMPREHENSIVE OUTREACH SERVICES TO ENROLLEES. 14

(V) IN ADDITION TO THE PR OVISIONS OF SUBPARAGRAPH (IV) 15
OF THIS PARAGRAPH, IF A MANAGED CARE ORGANIZATION DOES NOT COMPLY WITH 16
THE REQUIREMENTS OF PARAGRAPH (1) OF THIS SUBSECTION OR FAILS TO PROVIDE 17
EVIDENCE OF COMPLIAN CE TO THE DEPARTMENT UNDER SUBPARAGRAPH (II) OF 18
THIS PARAGRAPH, THE DEPARTMENT MAY: 19

1. IMPOSE A FINE ON THE MANAGED CARE 20
ORGANIZATION; 21

2. SUSPEND FURTHER ENROL LMENT INTO THE 22
MANAGED CARE ORGANIZATION; 23

3. WITHHOLD ALL OR PART OF THE CAPITATION RA TE 24
FROM THE MANAGED CARE ORGANIZATION; 25

4. TERMINATE THE PROVIDER AGREEMENT; OR 26

5. DISQUALIFY THE MANAGE D CARE ORGANIZATION 27
FROM FUTURE PARTICIPATION IN THE PROGRAM ESTABLISHED UNDER SUBSECTION 28
(A) OF THIS SECTION. 29

(VI) THE DEPARTMENT SHALL DEPOSIT FINES IMPOSED UNDER 30
SUBPARAGRAPH (V)1 OF THIS PARAGRAPH IN THE HEALTHCHOICE PERFORMANCE 31
INCENTIVE FUND ESTABLISHED UNDER § 15–103.5 OF THIS SUBTITLE. 32
34 SENATE BILL 244

(J) THE DEPARTMENT SHALL ADOP T REGULATIONS THAT E NSURE THAT 1
MANAGED CARE ORGANIZATIONS EMPLOY APPROPRIATE PERSONNEL TO: 2

(1) ENSURE THAT INDIVIDUA LS WITH SPECIAL NEED S OBTAIN 3
NEEDED SERVICES; AND 4

(2) COORDINATE THOSE SERVICES. 5

(K) (1) A MANAGED CARE ORGANIZATION SHALL REIMBURSE A HOSPITAL 6
EMERGENCY FACILITY AND PROVIDER FOR: 7

(I) HEALTH CARE SERVICES THAT MEET THE DEFINI TION OF 8
EMERGENCY SERVICES IN § 19–701 OF THIS ARTICLE; 9

(II) MEDICAL SCREENING SER VICES RENDERED TO ME ET THE 10
REQUIREMENTS OF THE FEDERAL EMERGENCY MEDICAL TREATMENT AND ACTIVE 11
LABOR ACT; 12

(III) MEDICALLY NECESSARY SERVICES IF THE MANAG ED CARE 13
ORGANIZATION AUTHORIZED, REFERRED, OR OTHERWISE ALLOWED THE ENROLLEE 14
TO USE THE EMERGENCY FACILITY AND THE MEDICALLY NECESSARY SERVICES ARE 15
RELATED TO THE CONDITION FOR WHICH THE ENROLLEE WAS ALLOWED TO USE THE 16
EMERGENCY FACILITY; AND 17

(IV) MEDICALLY NECESSARY S ERVICES THAT RELATE TO THE 18
CONDITION PRESENTED AND THAT ARE PROVIDE D BY THE PROVIDER IN THE 19
EMERGENCY FACILITY T O THE ENROLLEE IF TH E MANAGED CARE ORGAN IZATION 20
FAILS TO PROVIDE 24–HOUR ACCESS TO A PHY SICIAN AS REQUIRED B Y THE 21
DEPARTMENT. 22

(2) A PROVIDER MAY NOT BE REQUIRED TO OBTAIN P RIOR 23
AUTHORIZATION OR APP ROVAL FOR PAYMENT FR OM A MANAGED CARE 24
ORGANIZATION IN ORDER TO OBTAIN REIMBURSEMENT UNDER THIS SUBSECTION. 25

(L) THE DEPARTMENT SHALL: 26

(1) ESTABLISH AND MAINTAI N AN OMBUDSMAN PROGR AM AND A 27
LOCALLY ACCESSIBLE ENROLLEE HOTLINE; 28

(2) PERFORM FOCUSED MEDIC AL REVIEWS OF MANAGE D CARE 29
ORGANIZATIONS THAT I NCLUDE REVIEWS OF HO W THE MANAGED CARE 30
SENATE BILL 244 35

ORGANIZATIONS ARE PR OVIDING HEALTH CARE SERVICES TO SPE CIAL 1
POPULATIONS; 2

(3) PROVIDE TIMELY FEEDBA CK TO EACH MANAGED C ARE 3
ORGANIZATION ON ITS COMPLIANCE WITH THE DEPARTMENT’S QUALITY AND 4
ACCESS SYSTEM; 5

(4) ESTABLISH AND MAINTAIN WITHIN THE DEPARTMENT A PROCESS 6
FOR HANDLING PROVIDE R COMPLAINTS ABOUT MAN AGED CARE ORGANIZATI ONS; 7
AND 8

(5) ADOPT REGULATIONS RELATING TO APPEALS BY MANAGED CARE 9
ORGANIZATIONS OF PEN ALTIES IMPOSED BY TH E DEPARTMENT, INCLUDING 10
REGULATIONS PROVIDING FOR AN APPEAL TO T HE OFFICE OF ADMINISTRATIVE 11
HEARINGS. 12

(M) (1) SUBJECT TO PARAGRAPH (3) OF THIS SUBSECTION , THE 13
DEPARTMENT SHALL DELE GATE RESPONSIBILITY FOR MAINTAINING THE 14
OMBUDSMAN PROGRAM FO R A COUNTY TO THAT C OUNTY’S LOCAL HEALTH 15
DEPARTMENT ON THE REQUEST OF THE LOCAL HEALTH DEPARTMENT. 16

(2) A LOCAL HEALTH DEPARTMENT MAY NOT S UBCONTRACT THE 17
OMBUDSMAN PROGRAM. 18

(3) BEFORE THE DEPARTMENT DELEGATES RESPONSIBILITY TO A 19
LOCAL HEALTH DEPARTM ENT TO MAINTAIN THE OMBUDSMAN PROGRAM FO R A 20
COUNTY, A LOCAL HEALTH DEPAR TMENT THAT IS ALSO A MEDICAID PROVIDER 21
MUST RECEIVE THE APPROVAL OF TH E SECRETARY AND THE LOC AL GOVERNING 22
BODY. 23

(N) A MANAGED CARE ORGANIZATION MAY NOT: 24

(1) WITHOUT AUTHORIZATION BY THE DEPARTMENT, ENROLL AN 25
INDIVIDUAL WHO AT THE TIME IS A PROGRAM RECIPIENT; OR 26

(2) HAVE FACE –TO–FACE OR TELEPHONE C ONTACT WITH , OR 27
OTHERWISE SOLICIT, AN INDIVIDUAL WHO AT THE TIME IS A PROGRAM RECIPIENT 28
BEFORE THE PROGRAM RECIPIENT ENR OLLS IN THE MANAGED CARE 29
ORGANIZATION UNLESS: 30

(I) AUTHORIZED BY THE DEPARTMENT; OR 31

(II) THE PROGRAM RECIPIENT INITIATES CONTACT. 32
36 SENATE BILL 244

(O) (1) THE DEPARTMENT SHALL BE R ESPONSIBLE FOR ENROL LING 1
PROGRAM RECIPIENTS INTO MANAGED CARE ORGANIZATIONS. 2

(2) THE DEPARTMENT MAY CONTRACT WITH AN ENTITY TO PERFORM 3
THE ENROLLMENT FUNCTION. 4

(3) THE DEPARTMENT OR ITS ENR OLLMENT CONTRACTOR S HALL 5
ADMINISTER A HEALTH RISK ASSESSMENT DEVE LOPED BY THE DEPARTMENT TO 6
ENSURE THAT INDIVIDU ALS WHO NEED SPECIAL OR IMMEDIATE HEALTH CARE 7
SERVICES WILL RECEIVE THE SERVICES ON A TIMELY BASIS. 8

(4) THE DEPARTMENT OR ITS ENROLLMENT CONTRACTOR: 9

(I) MAY ADMINISTER THE HEALT H RISK ASSESSMENT ON LY 10
AFTER THE PROGRAM RECIPIENT HAS CHOSEN A MANAGED CAR E ORGANIZATION; 11
AND 12

(II) SHALL FORWARD THE RES ULTS OF THE HEALTH R ISK 13
ASSESSMENT TO THE MA NAGED CARE ORGANIZAT ION CHOSEN BY THE PROGRAM 14
RECIPIENT WITHIN 5 BUSINESS DAYS. 15

(P) FOR A MANAGED CARE OR GANIZATION WITH WHIC H THE SECRETARY 16
CONTRACTS TO PROVIDE SERVICES TO PROGRAM RECIPIENTS UN DER THIS 17
SECTION, THE SECRETARY SHALL ESTABLISH A MECHANISM TO INITIALLY ENSURE 18
THAT EACH HISTORIC P ROVIDER THAT MEETS T HE DEPARTMENT’S QUALITY 19
STANDARDS HAS THE OPPORTUNITY TO CONTINUE TO SERVE PROGRAM RECIPIENTS 20
AS A SUBCONTRACTOR OF AT LEAST ONE MANAGED CARE ORGANIZATION. 21

(Q) (1) THE DEPARTMENT SHALL MAKE CAPITATION PAYMENTS TO EACH 22
MANAGED CARE ORGANIZATION AS PROVIDED IN THIS SUBSECTION. 23

(2) IN CONSULTATION WITH THE INSURANCE COMMISSIONER, THE 24
SECRETARY SHALL: 25

(I) SET CAPITATION PAYMEN TS AT A LEVEL THAT I S 26
ACTUARIALLY ADJUSTED TO THE BENEFITS PROVIDED; AND 27

(II) ACTUARIALLY ADJUST TH E CAPITATION PAYMENT S TO 28
REFLECT THE RELATIVE RISK ASSUMED BY THE MANAGED CARE ORGANIZATION. 29

(3) IN ACTUARIALLY ADJUST ING CAPITATION PAYME NTS UNDER 30
PARAGRAPH (2)(II) OF THIS SUBSECTION, THE SECRETARY, IN CONSULTATION WITH 31
SENATE BILL 244 37

THE INSURANCE COMMISSIONER, SHALL TAKE INTO ACCO UNT, TO THE EX TENT 1
ALLOWED UNDER FEDERAL LAW, THE EXPENSES INCURRED BY THE MANAGED CARE 2
ORGANIZATION APPLICABLE TO THE BUSINESS OF PROVIDING CARE TO ENROLLED 3
INDIVIDUALS. 4

(R) (1) SCHOOL–BASED CLINICS AND MA NAGED CARE ORGANIZAT IONS 5
SHALL COLLABORATE TO PROVIDE CONTINUITY OF CARE TO ENROLLEES. 6

(2) SCHOOL–BASED CLINICS SHALL BE DEFINED BY THE 7
DEPARTMENT IN CONSULTATION WITH THE STATE DEPARTMENT OF EDUCATION. 8

(3) EACH MANAGED CARE ORG ANIZATION SHALL REQU IRE A 9
SCHOOL–BASED CLINIC TO PROV IDE TO THE MANAGED C ARE ORGANIZ ATION 10
INFORMATION, AS SPECIFIED BY THE DEPARTMENT, ABOUT AN ENCOUNTER W ITH 11
AN ENROLLEE OF THE M ANAGED CARE ORGANIZA TION BEFORE PAYING T HE 12
SCHOOL–BASED CLINIC. 13

(4) ON RECEIPT OF INFORMATION SPECIFIED BY THE DEPARTMENT, 14
THE MANAGED CARE ORG ANIZATION SHALL PAY, AT MEDICAID–ESTABLISHED 15
RATES, SCHOOL–BASED CLINICS FOR COVERED SERVICES PROVIDED TO ENROLLEES 16
OF THE MANAGED CARE ORGANIZATION. 17

(5) THE DEPARTMENT SHALL WORK WITH MANAGED CARE 18
ORGANIZATIONS AND SC HOOL–BASED CLINICS TO DEV ELOP COLLABORATION 19
STANDARDS, GUIDELINES, AND A PROCESS TO ENS URE THAT THE SERVICE S 20
PROVIDED ARE COVERED AND MEDICALLY APPROPRIATE AND THAT THE P ROCESS 21
PROVIDES FOR TIMELY NOTIFICATION AMONG THE PARTIES. 22

(6) EACH MANAGED CARE ORGANIZATION SHALL MAINTAIN RECORDS 23
OF ALL HEALTH CARE SERVICES: 24

(I) PROVIDED TO ITS ENROLLEES BY SCHOOL–BASED CLINICS; 25
AND 26

(II) FOR WHICH THE MANAGED CARE ORGANIZATION HAS BEEN 27
BILLED. 28

(S) THE DEPARTMENT SHALL ESTA BLISH STANDARDS FOR THE TIMELY 29
DELIVERY OF SERVICES TO ENROLLEES. 30

(T) (1) THE DEPARTMENT SHALL ESTA BLISH A DELIVERY SYS TEM FOR 31
SPECIALTY MENTAL HEA LTH SERVICES FOR ENR OLLEES OF MANAGED CA RE 32
ORGANIZATIONS. 33
38 SENATE BILL 244

(2) THE BEHAVIORAL HEALTH ADMINISTRATION SHALL: 1

(I) DESIGN AND MONITOR THE DELIVERY SYSTEM; 2

(II) ESTABLISH PERFORMANCE STANDARDS FOR PROVIDERS IN 3
THE DELIVERY SYSTEM; AND 4

(III) ESTABLISH PROCEDURES TO ENSURE APPROPRIAT E AND 5
TIMELY REFERRALS FRO M MANAGED CARE ORGAN IZATIONS TO THE DELI VERY 6
SYSTEM THAT INCLUDE: 7

1. SPECIFICATION OF THE DIAGNOSES AND CONDITIONS 8
ELIGIBLE FOR REFERRAL TO THE DELIVERY SYSTEM; 9

2. TRAINING AND CLINICAL GUIDANCE IN APPROPRIATE 10
USE OF THE DELIVERY SYSTEM FOR MANAGED CARE ORGANIZATION PRIMARY CARE 11
PROVIDERS; 12

3. PREAUTHORIZATION BY T HE UTILIZATION REVIE W 13
AGENT OF THE DELIVERY SYSTEM; AND 14

4. PENALTIES FOR A PATTE RN OF IMPROPER 15
REFERRALS. 16

(3) THE DEPARTMENT SHALL COLL ABORATE WITH MANAGED CARE 17
ORGANIZATIONS TO DEVELOP STANDARDS AND GUIDELINES FOR THE PROVISION OF 18
SPECIALTY MENTAL HEALTH SERVICES. 19

(4) THE DELIVERY SYSTEM SHALL: 20

(I) PROVIDE ALL SPECIALTY MENTAL HEALTH SERVIC ES 21
NEEDED BY ENROLLEES; 22

(II) FOR ENROLLEES WHO ARE DUALLY DIAGNOSED , 23
COORDINATE THE PROVISION OF SUBSTANCE USE DISORDER TREATMENT SERVICES 24
PROVIDED BY THE MANAGED CARE ORGANIZATIONS OF THE ENROLLEES; 25

(III) CONSIST OF A NETWORK OF QUALIFIED MENTAL HEALTH 26
PROFESSIONALS FROM ALL CORE DISCIPLINES; 27

(IV) INCLUDE LINKAGES WITH OTHER PUBLIC SERVICE 28
SYSTEMS; AND 29
SENATE BILL 244 39

(V) COMPLY WITH QUALITY A SSURANCE, ENROLLEE INPUT , 1
DATA COLLECTION, AND OTHER REQUIREMENTS SPECIFIED BY THE DEPARTMENT 2
IN REGULATION. 3

(5) THE DEPARTMENT MAY CONTRA CT WITH A MANAGED CA RE 4
ORGANIZATION FOR DEL IVERY OF SPECIALTY M ENTAL HEALTH SERVICE S IF THE 5
MANAGED CARE ORGANIZATION MEETS THE PERF ORMANCE STANDARDS ADOPTED 6
BY THE DEPARTMENT IN REGULATIONS. 7

(6) THE PROVISIONS OF § 15–1005 OF THE INSURANCE ARTICLE 8
APPLY TO THE DELIVER Y SYSTEM FOR SPECIAL TY MENTAL HEALTH SER VICES 9
ESTABLISHED UNDER TH IS SUBSECTION AND AD MINISTERED BY AN 10
ADMINISTRATIVE SERVICES ORGANIZATION. 11

(7) THE DEPARTMENT AND THE BEHAVIORAL HEALTH 12
ADMINISTRATION SHALL ENSURE THAT THE DELIVERY SYSTEM HAS AN A DEQUATE 13
NETWORK OF PROVIDERS AVAILABLE TO PROVIDE SUBSTANCE USE DISORD ER 14
TREATMENT FOR CHILDREN UNDER THE AGE OF 18 YEARS. 15

(U) THE DEPARTMENT SHALL INCL UDE A DEF INITION OF MEDICAL 16
NECESSITY IN ITS QUALITY AND ACCESS STANDARDS. 17

(V) (1) THE DEPARTMENT SHALL ADOP T REGULATIONS RELATI NG TO 18
ENROLLMENT, DISENROLLMENT, AND ENROLLEE APPEALS. 19

(2) PROGRAM RECIPIENTS SHALL HAVE THE RIGHT TO CHOOSE: 20

(I) THE MANAGED CARE ORGANIZATION WI TH WHICH THEY 21
ARE ENROLLED; AND 22

(II) THE PRIMARY CARE PROV IDER TO WHOM THEY AR E 23
ASSIGNED WITHIN THE MANAGED CARE ORGANIZATION. 24

(3) IF A RECIPIENT IS DIS ENROLLED AND REENROL LS WITHIN 120 25
DAYS AFTER THE RECIPIENT’S DISENROLLMENT, THE DEPARTMENT SHALL: 26

(I) ASSIGN THE RECIPIENT TO THE MANAGED CARE 27
ORGANIZATION IN WHICH THE RECIPIENT PREVIOUSLY WAS ENROLLED; AND 28

(II) REQUIRE THE MANAGED C ARE ORGANIZATION TO ASSIGN 29
THE RECIPIENT TO THE PRIMARY CARE PROVIDER OF RECORD AT THE TIME OF THE 30
RECIPIENT’S DISENROLLMENT. 31
40 SENATE BILL 244

(4) WHENEVER A RECIPIENT HAS TO SELECT A NEW MANAGED CARE 1
ORGANIZATION BECAUSE THE RECIPIENT ’S MANAGED CARE ORGAN IZATION HAS 2
DEPARTED FROM THE PR OGRAM ESTABLISHED UN DER SUBSECTION (A) OF THIS 3
SECTION, THE DEPARTING MANAGED CARE ORGANIZATION: 4

(I) SHALL PROVIDE A WRITTEN NOTICE TO THE REC IPIENT 60 5
DAYS BEFORE DEPARTING FROM THE PROGRAM ESTABLISHED UNDER SUBSECTION 6
(A) OF THIS SECTION; 7

(II) SHALL INCLUDE IN THE NOTICE THE NAME AND PROVIDER 8
NUMBER OF THE PRIMARY CARE PROVIDER ASSIGNED TO THE RECIPIENT AND THE 9
TELEPHONE NUMBER OF THE ENROLLMENT BROKER; AND 10

(III) WITHIN 30 DAYS AFTER DEPARTING FROM THE PROGRAM, 11
SHALL PROVIDE THE DEPARTMENT WITH A LIST OF ENROLLEES AND THE NAME OF 12
EACH ENROLLEE’S PRIMARY CARE PROVIDER. 13

(5) ON RECEIVING THE LIST PROVIDED BY THE MANA GED CARE 14
ORGANIZATION, THE DEPARTMENT SHALL PROVIDE THE LIST TO: 15

(I) THE ENROLLMENT BROKER TO ASSIST AND PROVID E 16
OUTREACH TO RECIPIENTS IN SELECTING A MANAGED CARE ORGANIZATION; AND 17

(II) THE REMAINING MANAGED CARE ORGANIZATIONS FOR THE 18
PURPOSE OF LINKING R ECIPIENTS WITH A PRI MARY CARE PROVIDER I N 19
ACCORDANCE WITH FEDERAL LAW AND REGULATION. 20

(6) SUBJECT TO SUBSECTION (DD)(4) AND (5) OF THIS SECTION , AN 21
ENROLLEE MAY DISENROLL FROM A MANAGED CARE ORGANIZATION: 22

(I) WITHOUT CAUSE IN THE MONTH FOLLOWING THE 23
ANNIVERSARY DATE OF THE ENROLLEE’S ENROLLMENT; AND 24

(II) FOR CAUSE , AT ANY TIME AS DETER MINED BY THE 25
SECRETARY. 26

(W) THE DEPARTMENT OR ITS SUBCONTRACTOR, TO THE EXTENT FEASIBLE 27
IN ITS MARKETING OR ENROLLM ENT PROGRAMS , SHALL HIRE INDIVIDUA LS 28
RECEIVING ASSISTANCE UNDER THE PROGRAM OF AID TO FAMILIES WITH 29
DEPENDENT CHILDREN ESTABLISHED UNDER TITLE IV, PART A OF THE SOCIAL 30
SECURITY ACT, OR THE SUCCESSOR TO THE PROGRAM. 31

SENATE BILL 244 41

(X) THE DEPARTMENT SHALL DISENROLL AN ENROLLEE WHO IS A CHILD IN 1
STATE–SUPERVISED CARE IF THE CHILD IS TRANSFERRED TO AN AREA OUTSIDE THE 2
TERRITORY OF THE MANAGED CARE ORGANIZATION. 3

(Y) THE SECRETARY SHALL ADOPT REGULATIONS TO CARRY OUT THIS 4
SECTION. 5

(Z) A MANAGED CARE O RGANIZATION SHALL PR OVIDE COVERAGE FOR 6
HEARING LOSS SCREENI NGS OF NEWBORNS PROV IDED BY A HOSPITAL B EFORE 7
DISCHARGE. 8

(AA) (1) THE DEPARTMENT SHALL PROV IDE ENROLLEES AND HE ALTH 9
CARE PROVIDERS WITH AN ACCURATE DIRECTOR Y OR OTHER LISTING O F ALL 10
AVAILABLE PROVIDERS: 11

(I) IN WRITTEN FORM, MADE AVAILABLE ON REQUEST; AND 12

(II) ON AN INTERNET DATABASE. 13

(2) THE DEPARTMENT SHALL UPDATE THE INTERNET DATABASE AT 14
LEAST EVERY 30 DAYS. 15

(3) THE WRITTEN DIRECTORY SHALL INCLUDE A CONS PICUOUS 16
REFERENCE TO THE INTERNET DATABASE. 17

(BB) A MANAGED CARE ORGANIZ ATION MAY NOT APPLY A PRIOR 18
AUTHORIZATION REQUIR EMENT FOR A PRESCRIP TION DRUG USED AS 19
POSTEXPOSURE PROPHYLAXIS FOR THE PREVENTION OF HIV IF THE PRESCRIPTION 20
DRUG IS PRESCRIBED F OR USE IN ACCORDANCE WITH CENTERS FOR DISEASE 21
CONTROL AND PREVENTION GUIDELINES. 22

(CC) THE SECRETARY SHALL ADOPT REGULATIONS FOR PHAR MACY 23
BENEFITS MANAGERS THAT CONTRACT WITH MANAGED CARE ORGANIZATIONS THAT 24
ESTABLISH REQUIREMEN TS FOR CONDUCTING AU DITS OF PHARMACIES O R 25
PHARMACISTS THAT ARE: 26

(1) TO THE EXTENT PRACTICABLE, SUBSTANTIVELY SIMILAR TO THE 27
AUDIT PROVISIONS UNDER § 15–1629 OF THE INSURANCE ARTICLE; AND 28

(2) CONSISTENT WITH FEDERAL LAW. 29

(DD) (1) THE DEPARTMENT SHALL ESTABLISH MECHANISMS FOR: 30

42 SENATE BILL 244

(I) IDENTIFYING A PROGRAM RECIPIENT’S PRIMARY CARE 1
PROVIDER AT THE TIME OF ENROLLMENT INTO A MANAGED CARE PROGRAM; AND 2

(II) MAINTAINING CONTINUIT Y OF CARE WITH THE P RIMARY 3
CARE PROVIDER IF: 4

1. THE PROVIDER HAS A CO NTRACT WITH A MANAGE D 5
CARE ORGANIZATION OR A CONTRACTED MED ICAL GROUP OF A MANA GED CARE 6
ORGANIZATION TO PROVIDE PRIMARY CARE SERVICES; AND 7

2. THE RECIPIENT DESIRES TO CONTINUE CARE WIT H 8
THE PROVIDER. 9

(2) IF A PROGRAM RECIPIENT ENR OLLS IN A MANAGED CA RE 10
ORGANIZATION AND REQ UESTS ASSIGNMENT TO A PARTICULAR P RIMARY CARE 11
PROVIDER WHO HAS A C ONTRACT WITH THE MAN AGED CARE ORGANIZATION OR A 12
CONTRACTED GROUP OF THE MANAGED CARE ORGANIZATION, THE MANAGED CARE 13
ORGANIZATION SHALL ASSIGN THE RECIPIENT TO THE PRIMARY CARE PROVIDER. 14

(3) (I) A PROGRAM RECIPIENT MAY REQUEST A CHANGE OF 15
PRIMARY CARE PROVIDE RS WITHIN THE SAME M ANAGED CARE ORGANIZA TION AT 16
ANY TIME. 17

(II) IF THE PRIMARY CARE P ROVIDER HAS A CONTRA CT WITH 18
THE MANAGED CARE ORG ANIZATION OR A CONTR ACTED GROUP OF THE M ANAGED 19
CARE ORGANIZATION , THE MANAGED CARE ORGANIZATION SHALL H ONOR A 20
REQUEST MADE UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH. 21

(4) IN ACCORDANCE WITH THE FEDERAL HEALTH CARE FINANCING 22
ADMINISTRATION’S GUIDELINES , A PROGRAM RECIPIENT MAY ELECT TO 23
DISENROLL FROM A MAN AGED CARE ORGANIZATI ON IF THE MA NAGED CARE 24
ORGANIZATION TERMINATES ITS CONTRACT WITH THE DEPARTMENT. 25

(5) A PROGRAM RECIPIENT MAY DISENROLL FROM A MANAGED CARE 26
ORGANIZATION TO MAIN TAIN CONTINUITY OF C ARE WITH A PRIMARY C ARE 27
PROVIDER IF: 28

(I) THE CONTRACT BETWEEN THE PRIMARY CARE PRO VIDER 29
AND THE MANAGED CARE ORGANIZATION OR CONT RACTED GROUP OF THE 30
MANAGED CARE ORGANIZATION TERMINATES BECAUSE: 31

1. THE MANAGED CARE ORGA NIZATION OR 32
CONTRACTED GROUP OF THE MANAGED CARE ORG ANIZATION TERMINATES THE 33
SENATE BILL 244 43

PROVIDER’S CONTRACT FOR A REA SON OTHE R THAN QUALITY OF CA RE OR THE 1
PROVIDER’S FAILURE TO COMPLY WITH CONTRACTUAL REQ UIREMENTS RELATED 2
TO QUALITY ASSURANCE ACTIVITIES; 3

2. A. THE MANAGED CARE ORGA NIZATION OR 4
CONTRACTED GROUP OF THE MANAGED CARE ORG ANIZATION REDUCES TH E 5
PRIMARY CARE PROVIDER’S CAPITATED OR APPLICABLE FEE FOR SERVICES RATES; 6

B. THE REDUCTION IN RATE S IS GREATER THAN TH E 7
ACTUAL CHANGE IN RAT ES OR CAPITATION PAI D TO THE MANAGED CAR E 8
ORGANIZATION BY THE DEPARTMENT; AND 9

C. THE PROVIDER AND THE MANAGED CARE 10
ORGANIZATION OR CONTRACTED GROUP OF THE MANAGED CARE ORGANIZATION 11
ARE UNABLE TO NEGOTIATE A MUTUALLY ACCEPTABLE RATE; OR 12

3. THE PROVIDER CONTRACT BETWEEN THE PROVIDER 13
AND THE MANAGED CARE ORGANIZATION IS TERMINATED BECAUSE THE MANAGED 14
CARE ORGANIZATION IS ACQUIRED BY ANOTHER ENTITY; AND 15

(II) 1. THE PROGRAM RECIPIENT DESIRES TO CONTINUE TO 16
RECEIVE CARE FROM THE PRIMARY CARE PROVIDER; 17

2. THE PROVIDER CONTRACT S WITH AT LEAST ONE 18
OTHER MANAGED CARE O RGANIZATION OR CONTR ACTED GROUP OF A MAN AGED 19
CARE ORGANIZATION; AND 20

3. THE ENROLLEE NOTIFIES THE DEPARTMENT OR THE 21
DEPARTMENT’S DESIGNEE OF THE ENROLLEE’S INTENTION WITHIN 90 DAYS AFTER 22
THE CONTRACT TERMINATION. 23

(6) THE DEPARTMENT SHALL PROV IDE TIMELY NOTIFICAT ION TO 24
THE AFFECTED MANAGED CARE ORGANIZATION OF AN ENROLLEE’S INTENTION TO 25
DISENROLL UNDER THE PROVISIONS OF PARAGRAPH (5) OF THIS SUBSECTION. 26

REVISOR’S NOTE: This section formerly was § 15–103(b)(1) through (26) and (29) 27
through (33) and (f) of this subtitle. 28

In subsection (b)(1)(ii), the phrase “at least” was added for clarity. 29

In subsection (c), the reference to the “Maryland Children’s Health Program” 30
was deleted and duplicative language for Maryland Children ’s Health 31
Program has been added as § 15–306 of this title to reflect the organization of 32
this title. 33
44 SENATE BILL 244

In subsection (i)( 1)(xviii), the phrase “tab on the State –designated health 1
information exchange website required under § 19–145.1(b)(2)(iv) of this 2
article” was substituted for the former phrase “after the tab on the 3
State–designated he alth information exchange website required under § 4
19–145(b)(2)(iv) of this article is developed ” to reflect that the tab has been 5
developed and to correct an erroneous cross–reference. 6

In subsections (i)(3)(v)5 and (v)(4), the phrase “program established under 7
subsection (a) of this section” was substituted for the former references to the 8
“Maryland Medicaid Managed Care Program ” and the “HealthChoice 9
Program”, respectively, for consistency throughout this section. 10

In subsection (dd)(3)(ii), the phrase “made under subparagraph (i) of this 11
paragraph” was added for clarity. 12

Throughout this section, the term “substance use disorder” is substituted for 13
the former references to “substance abuse” and “alcohol and drug abuse” and 14
“with substance us e disorders ” is substituted for the former reference to 15
“substance abusing ” to update terminology to that used currently in the 16
behavioral health community. 17

The only other changes were in style. 18

15–103.2. 19

(A) IN THIS SECTION , “COMMITTEE” MEANS THE MARYLAND MEDICAID 20
ADVISORY COMMITTEE. 21

(B) THE DEPARTMENT SHALL ESTA BLISH THE MARYLAND MEDICAID 22
ADVISORY COMMITTEE. 23

(C) (1) THE COMMITTEE SHALL BE CO MPOSED OF NOT MORE T HAN 25 24
MEMBERS. 25

(2) THE MAJORITY OF THE MEMBERS OF THE COMMITTEE SHALL BE 26
ENROLLEES OR ENROLLEE ADVOCATES. 27

(3) AT LEAST FIVE MEMBERS OF THE COMMITTEE SHALL BE 28
ENROLLEES REPRESENTATIVE OF THE ENTIRE MEDICAID POPULATION. 29

(4) THE COMMITTEE MEMBERS SHALL INCLUDE: 30

(I) AT LEAST FIVE CURRENT OR FORMER ENROLLEES OR THE 31
PARENTS OR GUARDIANS OF CURRENT OR FORMER ENROLLEES; 32
SENATE BILL 244 45

(II) PROVIDERS WHO ARE FAMILIAR WITH THE MEDICAL NEEDS 1
OF LOW –INCOME POPULATION GR OUPS, INCLUDING BOARD –CERTIFIED 2
PHYSICIANS; 3

(III) HOSPITAL REPRESENTATIVES; 4

(IV) AT LEAST FIVE BUT NOT MORE THAN 10 ADVOCATES FOR 5
THE MEDICAID POPULATION , INCLUDING REPRESENTATIVES OF SPECIAL NEE DS 6
POPULATIONS, SUCH AS: 7

1. CHILDREN WITH SPECIAL NEEDS; 8

2. INDIVIDUALS WITH PHYSICAL DISABILITIES; 9

3. INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES; 10

4. INDIVIDUALS WITH MENTAL ILLNESS; 11

5. INDIVIDUALS WITH BRAIN INJURIES; 12

6. MEDICAID AND MEDICARE DUAL ELIGIBLES; 13

7. INDIVIDUALS WHO ARE H OMELESS OR HAVE 14
EXPERIENCED HOMELESSNESS; 15

8. INDIVIDUALS ENROLLED IN HOME – AND 16
COMMUNITY–BASED SERVICES WAIVERS; 17

9. ELDERLY INDIVIDUALS; 18

10. LOW–INCOME INDIVIDUALS A ND INDIVIDUALS 19
RECEIVING BENEFITS T HROUGH THE TEMPORARY ASSISTANCE FOR NEEDY 20
FAMILIES PROGRAM; AND 21

11. INDIVIDUALS RECEIVING SUBSTANCE USE 22
TREATMENT SERVICES; 23

(V) TWO MEMBERS OF THE SENATE FINANCE COMMITTEE, 24
APPOINTED BY THE PRESIDENT OF THE SENATE; AND 25

(VI) THREE MEMBERS OF THE HOUSE OF DELEGATES, 26
APPOINTED BY THE SPEAKER OF THE HOUSE. 27
46 SENATE BILL 244

(5) A DESIGNEE OF EACH OF THE FOLLOWING SHALL SERVE AS AN EX 1
OFFICIO MEMBER OF THE COMMITTEE: 2

(I) THE SECRETARY OF HUMAN SERVICES; 3

(II) THE EXECUTIVE DIRECTOR OF THE MARYLAND HEALTH 4
CARE COMMISSION; AND 5

(III) THE MARYLAND ASSOCIATION OF COUNTY HEALTH 6
OFFICERS. 7

(6) THE SECRETARY SHALL APPOI NT NONVOTING MEMBERS FROM 8
MANAGED CARE ORGANIZATIONS WHO MA Y PARTICIPATE IN COMMITTEE 9
MEETINGS, UNLESS THE COMMITTEE MEETS IN CLOSED SESSION AS PROVIDED IN § 10
3–305 OF THE GENERAL PROVISIONS ARTICLE. 11

(7) (I) EXCEPT AS SPECIFIED IN PARAGRAPHS (4)(V) AND (VI) AND 12
(5) OF THIS SUBSECTION, THE MEMBERS OF THE COMMITTEE SHALL BE APPOINTED 13
BY THE SECRETARY AND SERVE FOR A 4–YEAR TERM. 14

(II) IN MAKING APPOINTMENT S TO THE COMMITTEE, THE 15
SECRETARY SHALL PROVIDE FOR CONTINUITY AND ROTATION. 16

(III) IN APPOINTING CONSUMER MEMBERS TO THE COMMITTEE, 17
THE SECRETARY SHALL SEEK RECOMMENDATIONS FROM: 18

1. THE STATE PROTECTION AND ADVOCACY SYSTEM 19
ORGANIZATION; 20

2. THE STATEWIDE INDEPENDENT LIVING COUNCIL; 21

3. THE DEVELOPMENTAL DISABILITIES COUNCIL; 22

4. THE DEPARTMENT OF DISABILITIES; 23

5. THE DEPARTMENT OF AGING; 24

6. CONSUMER ADVOCACY ORGANIZATIONS; AND 25

7. THE PUBLIC. 26

SENATE BILL 244 47

(D) (1) EXCEPT AS PROVIDED IN PARAGRAPH (2) OF THIS SUBSECTION, A 1
MEMBER OF THE COMMITTEE: 2

(I) MAY NOT RECEIVE COMPENSATION; BUT 3

(II) IS ENTITLED TO REIMBU RSEMENT FOR EXPENSES UND ER 4
THE STANDARD STATE TRAVEL REGULATIONS, AS PROVIDED IN THE STATE 5
BUDGET. 6

(2) A MEMBER OF THE COMMITTEE WHO IS AN E NROLLEE IS 7
ENTITLED TO REIMBURSEMENT FOR: 8

(I) EXPENSES FOR PERSONAL AND DEPENDENT CARE 9
INCURRED DURING THE MEETING AND DURING TRAVEL TIME TO AND FROM THE 10
MEETING; 11

(II) EXPENSES FOR COGNITIV E SUPPORTS RELATED T O THE 12
MEETING; AND 13

(III) APPROPRIATE TRANSPORT ATION TO AND FROM TH E 14
MEETING. 15

(3) ON REQUEST , THE DEPARTMENT SHALL PROV IDE FOR A 16
DEDICATED DEPARTMENT STAFF PERSON: 17

(I) TO REVIEW MEETING MAT ERIALS WITH ENROLLEE 18
MEMBERS IN ADVANCE OF A MEETING BY TELEPHONE OR IN PERSON; AND 19

(II) TO PROVIDE REFERRALS TO ADVOCACY ORGANIZATIONS. 20

(E) (1) THE SECRETARY SHALL APPOI NT THE CHAIR OF THE 21
COMMITTEE. 22

(2) THE DEPARTMENT SHALL PROVIDE STAFF FOR THE COMMITTEE. 23

(3) THE COMMITTEE SHALL DETERMINE THE TIMES AND PLACES OF 24
ITS MEETINGS. 25

(4) (I) THE CHAIR OF THE COMMITTEE AND THE STA FF FOR THE 26
COMMITTEE SHALL PROVI DE THE AGENDA , MINUTES, AND ANY WRITTEN 27
MATERIALS TO BE PRESENTED OR DISCUSSED AT A ME ETING TO THE MEMBERS OF 28
THE COMMITTEE AT LEAST 5 DAYS BEFORE THE MEETING. 29

48 SENATE BILL 244

(II) THE AGENDA, MINUTES, AND WRITTEN MATERIAL S SHALL 1
BE PROVIDED TO MEMBE RS OF THE COMMITTEE IN A MANNER AND FORMAT THAT 2
REASONABLY ACCOMMODATES THE SPECIFIC NEEDS OF THE MEMBER. 3

(F) IN ADDITION TO ANY DU TIES IMPOSED BY FEDE RAL LAW AND 4
REGULATION, THE COMMITTEE SHALL: 5

(1) ADVISE THE SECRETARY ON THE IMPLEMENTATION, OPERATION, 6
AND EVALUATION OF MANAGED CARE PROGRAMS UNDER THIS SECTION; 7

(2) REVIEW AND MAKE RECOM MENDATIONS ON THE RE GULATIONS 8
DEVELOPED TO IMPLEMENT MANAGED CARE PROGRAMS UNDER § 15–103.1 OF THIS 9
SUBTITLE; 10

(3) REVIEW AND MAKE RECOM MENDATIONS ON THE ST ANDARDS 11
USED IN CONTRACTS BE TWEEN THE DEPARTMENT AND MANAGE D CARE 12
ORGANIZATIONS; 13

(4) REVIEW AND MAKE RECOMMENDATIONS ON THE DEPARTMENT’S 14
OVERSIGHT OF QUALITY ASSURANCE STANDARDS; 15

(5) REVIEW DATA COLLECTED BY THE DEPARTMENT FROM MANAGED 16
CARE ORGANIZATIONS PARTICIPATING IN THE PROGRAM AND DATA COLLECTED BY 17
THE MARYLAND HEALTH CARE COMMISSION; 18

(6) PROMOTE THE DISSEMINA TION OF MANAGED CARE 19
ORGANIZATION PERFORM ANCE INFORMATION , INCLUDING LOSS RATIO S, TO 20
ENROLLEES IN A MANNE R THAT FACILITATES Q UALITY COMPARISONS A ND USES 21
LAYMAN’S LANGUAGE; 22

(7) ASSIST THE DEPARTMENT IN EVALUATING THE ENROL LMENT 23
PROCESS; AND 24

(8) REVIEW REPORTS OF THE OMBUDSMEN. 25

REVISOR’S NOTE: This section formerly was § 15–103(b)(27) of this subtitle. 26

Subsection (a) is new language added to state expressly that which only was 27
implied in the former § 15–103(b)(27), that references to “the Committee” were 28
references to the Maryland Medicaid Advisory Committee. 29

In subsection (c)(4)(iv)11, the term “substance use ” is substituted for the 30
former reference to “substance abuse ” to update terminology to that used 31
currently in the behavioral health community. 32
SENATE BILL 244 49

In subsection (c)(7)(i), the reference to paragraph (4)(v) and (vi) was 1
substituted for the former reference to paragraph (4) for clarity. 2

The only other changes were in style. 3

15–103.5. 4

(b) (1) The Department shall pay all fines collected under [§ 15–103(b)(12)(v)] 5
§ 15–103.1(I)(3)(V) of this subtitle and penalties collected under [§ 15–103.7(e)(2)(iv)] § 6
15–103.9(E)(2)(IV) of this subtitle to the Comptroller of the State. 7

15–103.8. 8

(a) (2) Except as provided in [§ 15–103.8] § 15–103.10 of this subtitle, the 9
Department is not required to adopt regulations under paragraph (1) of this subsection for 10
any change that may be made through a process other than the regulatory process. 11

15–109. 12

(b) Except as provided in [§ 15–103(a)(2)(ii)] § 15–103(B)(2) of this subtitle, to 13
determine eligibility under the Program, the Department annually shall set the allowable 14
yearly income levels in amounts at least equal to the following: 15

(1) Family of 1 – $2,500. 16

(2) Family of 2 – $3,000. 17

(3) Family of 3 – $3,500. 18

(4) Family of 4 – $4,000. 19

(5) Family of 5 or more – $4,500 plus an increase of $500 for each family 20
member in excess of 5. 21

15–148. 22

(a) Except for a drug or device for which the U.S. Food and Drug Administration 23
has issued a black box warnin g, the Program [and the Maryland Children ’s Health 24
Program] may not apply a prior authorization requirement for a contraceptive drug or 25
device that is: 26

(1) (i) An intrauterine device; or 27

(ii) An implantable rod; 28

50 SENATE BILL 244

(2) Approved by the U.S. Food and Drug Administration; and 1

(3) Obtained under a prescription written by an authorized prescriber. 2

(b) The Program [and the Maryland Children ’s Health Program ] shall provide 3
coverage for a single dispensing to an enrollee of a supply of prescription contraceptives for 4
a 12–month period. 5

15–152. 6

(a) The Program [and the Maryland Children ’s Health Program ] shall provide 7
coverage for services rendered to an enrollee by a licensed pharmacist acting within the 8
pharmacist’s lawful scope of practice to the same extent as services rendered by any other 9
licensed health care provider. 10

(b) Reimbursement for services provided under subsection (a) of this section may 11
not be conditioned on whether the licensed pharmacist is: 12

(1) Employed by a physician, pharmacy, or facility; or 13

(2) Acting under a physician’s orders. 14

15–158. 15

The Program [and the Maryland Children’s Health Program] may not require prior 16
authorization for a transfer to a special pediatric hospital. 17

15–301. 18

(b) The Maryland Children ’s Health Program shall provide, subject to the 19
limitations of the State budget and any other requirements im posed by the State and as 20
permitted by federal law or waiver, comprehensive medical care and other health care 21
services to an individual who: 22

(1) Does not qualify for coverage under [§ 15–103(a)(2)] § 15–103(B) of 23
this title; and 24

15–304. 25

(b) (2) In a ddition to the school –based outreach program established under 26
subsection (a) of this section, the Department, in consultation with the Maryland Medicaid 27
Advisory Committee established under [§ 15–103(b)] § 15–103.2 of this title, shall develop 28
mechanisms for outreach for the program with a special emphasis on identifying children 29
who may be eligible for program benefits under the Maryland Children ’s Health Program 30
established under § 15–301 of this subtitle. 31

SENATE BILL 244 51

15–305. 1

(A) ON OR BEFORE JANUARY 1, 2025, SUBJECT TO THE LIMITATI ONS OF 2
THE STATE BUDGET AND AS PERMITTED BY FEDERAL LAW, THE DEPARTMENT: 3

(1) SHALL ESTABLISH AN EXPRESS LANE ELIGIBILITY PROGRAM TO 4
ENROLL INDIVIDUALS IN THE PROGRAM AND THE MARYLAND CHILDREN’S HEALTH 5
PROGRAM BASED ON ELIG IBILITY FINDINGS BY THE SUPPLEMENTAL NUTRITION 6
ASSISTANCE PROGRAM; 7

(2) MAY NOT CONSIDER ANY OTHER INCOME OR ELIG IBILITY 8
REQUIREMENTS; 9

(3) TO THE EXTENT THAT A WAIVER IS NEEDED TO MAXIMIZE THE 10
NUMBER OF STATE RESIDENTS WHO M AY QUALIFY FOR THE EXPRESS LANE 11
ELIGIBILITY PROGRAM, SHALL APPLY TO THE CENTERS FOR MEDICARE AND 12
MEDICAID SERVICES FOR ONE OR MORE WAIVERS UNDER § 1115 OF THE FEDERAL 13
SOCIAL SECURITY ACT TO IMPLEMENT THE EXPRESS LANE ELIGIBILITY PROGRAM; 14
AND 15

(4) SUBJECT TO SUBSECTION (B) OF THIS SECTION, SHALL MAKE ALL 16
REASONABLE EFFORTS T O EXPEDITE ENROLLMEN T OF ELIGIBLE INDIVI DUALS IN 17
THE EXPRESS LANE ELIGIBILITY PROGRAM. 18

(B) THE DEPARTMENT MAY PROPOSE OR IMPLEMENT THE USE OF EXPRESS 19
LANE ELIGIBILITY FOR RENEW ALS BEFORE PROPOSING OR IMPLEMENTING THE 20
USE OF EXPRESS LANE ELIGIBILITY FOR INITIAL ENROLLMENT. 21

REVISOR’S NOTE: This section repeats the provisions of § 15–103(a)(5) of this title, 22
as it relates to the Maryland Children’s Health Program, to reflect the 23
organization of the title. 24

15–306. 25

SUBJECT TO THE LIMITATIONS OF THE STATE BUDGET AND AS PERMITTED BY 26
FEDERAL LAW OR WAIVE R, THE MARYLAND CHILDREN’S HEALTH PROGRAM MAY 27
PROVIDE GUARANTEED E LIGIBILITY FOR EACH ENROLLEE FOR UP TO 6 MONTHS 28
UNLESS AN ENROLLEE OBTAINS HEALTH INSURANCE THROUGH ANOTHER SOURCE. 29

REVISOR’S NOTE: This section repeats the provisions of § 15–103(b)(3) of this title, 30
as it relates to the Maryland Children’s Health Program, to reflect the 31
organization of the title. 32

15–307. 33
52 SENATE BILL 244

(A) EXCEPT FOR A DRUG OR DEVICE FOR WHICH THE U.S. FOOD AND DRUG 1
ADMINISTRATION HAS IS SUED A BLACK BOX WAR NING, THE MARYLAND 2
CHILDREN’S HEALTH PROGRAM MAY NOT APPLY A PRIOR AUTHORIZATIO N 3
REQUIREMENT FOR A CONTRACEPTIVE DRUG OR DEVICE THAT IS: 4

(1) (I) AN INTRAUTERINE DEVICE; OR 5

(II) AN IMPLANTABLE ROD; 6

(2) APPROVED BY THE U.S. FOOD AND DRUG ADMINISTRATION; AND 7

(3) OBTAINED UNDER A PRESCRIPTION WRITTEN BY AN AUTHORIZED 8
PRESCRIBER. 9

(B) THE MARYLAND CHILDREN’S HEALTH PROGRAM SHALL PROVIDE 10
COVERAGE FOR A SINGL E DISPENSING TO AN E NROLLEE OF A SUPPLY OF 11
PRESCRIPTION CONTRACEPTIVES FOR A 12–MONTH PERIOD. 12

REVISOR’S NOTE: This section repeats the provisions of § 15–148 of this title, as it 13
relates to the Maryland Children’s Health Program, to reflect the organization 14
of the title. 15

15–308. 16

(A) THE MARYLAND CHILDREN’S HEALTH PROGRAM SHALL PROVIDE 17
COVERAGE FOR SERVICE S RENDERED TO AN ENR OLLEE BY A LICENSED 18
PHARMACIST ACTING WITHIN THE PHARMACIST’S LAWFUL SCOPE OF PR ACTICE TO 19
THE SAME EXTENT AS SERVICES RENDERED BY ANY OTHER LICENSED HEALTH CARE 20
PROVIDER. 21

(B) REIMBURSEMENT FOR SERVICES PROVIDED UNDER SUBSECTION (A) OF 22
THIS SECTION MAY NOT BE CONDITIONED ON WHETHER THE LICENSED PHARMACIST 23
IS: 24

(1) EMPLOYED BY A PHYSICIAN, PHARMACY, OR FACILITY; OR 25

(2) ACTING UNDER A PHYSICIAN’S ORDERS. 26

REVISOR’S NOTE: This section repeats the provisions of § 15–152 of this title, as it 27
relates to the Maryland Children’s Health Program, to reflect the organization 28
of the title. 29

15–309. 30
SENATE BILL 244 53

THE MARYLAND CHILDREN’S HEALTH PROGRAM MAY NOT REQUI RE PRIOR 1
AUTHORIZATION FOR A TRANSFER TO A SPECIAL PEDIATRIC HOSPITAL. 2

REVISOR’S NOTE: This section repeats the provisions of § 15–158 of this title, as it 3
relates to the Maryland Children’s Health Program, to reflect the organization 4
of the title. 5

SECTION 3. AND BE IT FURTHER ENACTED, That it is the intent of the General 6
Assembly that, except as expressly provided in this Act, this Act shall be construed as a 7
nonsubstantive revision and may not otherwise be construed to render any substantive 8
change in the law of the State. 9

SECTION 4. AND BE IT FURTHER ENACTED, That the Revisor’s Notes contained 10
in this Act are not law and may not be considered to have been enacted as part of this Act. 11

SECTION 5. AND BE IT FURTHER ENACTED, That the publisher of the 12
Annotated Code of Maryland, in consultation with and subject to the approval of the 13
Department of Legislative Services, shall correct, with no further action required by the 14
General Assembly, cross–references and terminology rendered incorrect by this Act or by 15
any other Act of the General Assembly of 2026 that affects provisions enacted by this Act. 16
The publisher shall adequately describe any correction that is made in an editor ’s note 17
following the section affected. 18

SECTION 6. AND BE IT FURTHER ENACTED, That this Act shall take effect 19
October 1, 2026. 20

Approved:
________________________________________________________________________________
Governor.
________________________________________________________________________________
President of the Senate.
________________________________________________________________________________
Speaker of the House of Delegates.