Skip to Main Content
<< Back | Return to Main COMAR Search Page

17 records match your request.

FileAbstract
10.07.11.00.htm 10.07.11.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 07 HOSPITALS Chapter 11 Health Maintenance Organizations Authority: Health-General Article, §19-701 et seq. Insurance Article, §2-109(a)c) Annotated Code of Maryland
10.07.11.01.htm 10.07.11.01. 01 Scope.. The purpose of these regulations is to regulate various phases of the operations of health maintenance organizations in accordance with the mandates of Health-General Article, §19-701―19-734, Annotated Code of Maryland.
10.07.11.01-1.htm 10.07.11.01-1. 01-1 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Board" means the Board of Physicians.. 1-1) "Certified nurse practitioner" has the meaning stated in Health Occupations Article, Title 8, Annotated Code of Maryland.2) "Commissioner" means the Insurance Commissioner of Maryland.. 3) "Department" means the Department of Health and Mental Hygiene.. 4) "Enrollee" means a person who has entered into a health care services co
10.07.11.02.htm 10.07.11.02. 02 Service Requirements.. A. The HMO shall provide the services required by the Maryland Health Maintenance Organization Act of 1975, Health-General Article, §19-701(d) Annotated Code of Maryland.B. The HMO shall make available and encourage appropriate history and baseline examinations for each enrollee within a reasonable time of enrollment set by the HMO. Medical problems that are a potential hazard to the person's health shall be identified and a course of action
10.07.11.03.htm 10.07.11.03. 03 Quality Assurance Requirements ― Program Planning and Evaluation.. A. The HMO shall have a written program plan that is updated and reviewed at least every 3 years.. B. The plan shall include the following information:. 1) Statistics on age, sex, and other general demographic data used to determine the health care needs of its population;2) Identification of the major health problems in the enrolled population;. 3) Identification of enrolled special groups that
10.07.11.04.htm 10.07.11.04. 04 Peer Review.. A. Internal Review. The HMO shall have an internal peer review system that will evaluate the utilization of services and the quality of health care provided enrollees. The review system shall:1) Provide for review by appropriate health professionals of the process followed in the provision of health services;2) Use systematic data collection of performances and patient results;. 3) Provide interpretation of this data to the practitioners;. 4) Review and update cont
10.07.11.05.htm 10.07.11.05. 05 Medical Records.. A. The HMO shall maintain an individual record for each patient according to accepted professional principles and the provisions of these regulations, with entries kept current, dated, and signed by a physician or other medical professional.B. All information contained in the medical records and information received from physicians, surgeons, certified nurse practitioners, or hospitals, incident to the health care practitioner-patient or hospital-patient relatio
10.07.11.06.htm 10.07.11.06. 06 Statistics.. The HMO shall provide the Department with full access to all operational and statistical data to enable the Department to verify the HMO's compliance and to enable the Department to conduct specific statistical studies with respect to current status of various segments of the enrolled population.
10.07.11.07.htm 10.07.11.07. 07 Personnel.. A. When applicable, each staff member of the HMO shall be licensed as required by State and local law, and meet acceptable professional qualifications or have qualified by means of an occupational proficiency examination or through acceptable training. Provider staff patterns shall be designed to meet enrollee needs.B. The HMO shall provide orientation for all new employees and require continuing education of all professional and supportive personnel which reflect
10.07.11.08.htm 10.07.11.08. 08 Policy Formulation.. A. The HMO shall have written policies governing the provision of the HMO services according to stated objectives of the HMO. The policies shall be developed in consultation with the executive officer, representative professionals, including one or more physicians, nursing service personnel associated with the service, and one or more enrollee representative or representatives. Policies shall be approved by the governing authority and reviewed an
10.07.11.09.htm 10.07.11.09. 09 Access and Availability of Services.. A. Regular Hours.. 1) With respect to all services it furnishes, whether direct or through contractual arrangements, an HMO shall provide for regular hours during which an enrollee may receive services.2) An HMO that provides services directly to its enrollees through its staff members shall have an orderly system for scheduling the provision of services to enrollees in a timely manner, taking into account the immediacy of need for services.
10.07.11.10.htm 10.07.11.10. 10 Physician Availability.. A. The HMO shall have a physician available at all times to provide diagnostic and treatment services. The HMO shall assure that every enrollee seen for a medical complaint is evaluated under the direction of a physician and that every enrollee receiving diagnostic evaluation or treatment is under the direct medical management of an HMO physician who provides continuing medical management.B. Each enrollee shall have an opportunity to sele
10.07.11.11.htm 10.07.11.11. 11 Complaint System for Quality of Care Issues.. A. The HMO shall have a:. 1) Written procedure to assist and respond to enrollees, families, and providers on complaints concerning quality of care issues; and2) Designated department to handle complaints.. B. Quality of care issues include, but are not necessarily limited to:. 1) Bad outcomes related to poor care;. 2) Failure to follow-up on diagnostic procedures;.
10.07.11.12.htm 10.07.11.12. 12 Inspections.. A. HMO to Be Open for Inspection. An HMO shall be open to inspection by representatives of the Department and by any agency designated by the Department.B. Frequency of Inspection.. 1) The Department shall inspect each HMO periodically at reasonable times.. 2) The Department shall monitor continuously the health care services of an HMO:. a) From the time of notice by the Commissioner that the HMO is not operating in a fiscally sound mani) The Commissioner notif
10.07.11.13.htm 10.07.11.13. 13 Repealed..
10.07.11.14.htm 10.07.11.14. 14 Waiver Authority.. The Department may grant waivers to the provisions of these regulations when this action is demonstrated to be in the best interests of the general public. Waivers may be granted for a 1-year period, are renewable, and are subject to reconsideration at any time.
10.07.11.9999.htm 10.07.11.9999. Administrative History Effective date: June 16, 1978 (5:12 Md. R. 967). Regulations .01E, .02, .03. .04B. .05D, .07E, .09B, .10B, .11A, .12B and C amended effective June 29, 1987 (14:13 Md. R. 1472)Regulation .01 amended effective June 22, 1992 (19:12 Md. R. 1134). Regulation .01 recodified to Regulation .01-1 and the Scope paragraph codified as Regulation .01 in May, 1993Regulation .01-1B amended effective December 9, 2004 (31:24 Md. R. 1726).
<< Back | Return to Main COMAR Search Page