Md. Code Regs. 31.17.01.03

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.17.01.03 - Selection Criteria for Plan Administrator

A. The Board may select an administrator to be the Plan Administrator only if the administrator:

(1) Satisfies the requirements listed in §§C-I of this regulation; and

(2) Meets all other terms that are established in any contract between the administrator and the Board.

B. The Board may select more than one Plan Administrator to administer different benefits or administrative functions of the Plan.

C. Proven Ability to Provide Health Insurance Coverage to Individuals. An administrator shall provide evidence to the Board that it has at least 3 years experience of:

(1) Providing health plan benefits under insured contracts that cover at least 15,000 lives per year;

(2) Administering health plans for self-funded employer health plans that cover at least 15,000 lives per year;

(3) Enrolling at least 15,000 lives per year in the administrator's capacity as a managed care organization; or

(4) Insuring, administering, or enrolling at least 15,000 lives per year through a combination of any of the health plans or programs listed in §C(1)-(3) of this regulation.

D. Efficiency and Timeliness of Administrator's Claim Processing Procedures.

(1) A carrier shall provide evidence to the Board that it has procedures in place to comply with:

(a) The claim processing procedures required under Insurance Article, §§ 15-1004 -15-1006, 15-1008, and 15-1009, Annotated Code of Maryland, for members covered under the Plan; and

(b) Any notice requirements specified by the Board in the request for proposals for the Plan Administrator.

(2) An administrator that is not a carrier shall provide the following to the Board:

(a) A detailed description of the claim procedures and processes that the administrator uses;

(b) An assurance that the administrator shall accept the uniform claims form as adopted by the Commissioner under Insurance Article, § 15-1003, Annotated Code of Maryland, for claims submitted on behalf of members of the Plan;

(c) An assurance that the administrator shall comply with the uniform claims forms regulations in COMAR 31.10.11 for claims submitted on behalf of members of the Plan;

(d) An assurance that the administrator shall pay claims for members of the Plan within the time required by Insurance Article, § 15-1005, Annotated Code of Maryland;

(e) An assurance that if the administrator denies a member's claim, the administrator, upon request of the member, shall give written notice to the member that states fully the reason for the denial;

(f) An assurance that the administrator shall comply with the requirements regarding retroactive denial of reimbursement as found in Insurance Article, § 15-1008, Annotated Code of Maryland, for claims for members of the Plan;

(g) An assurance that the administrator shall comply with the requirements regarding reimbursement for preauthorized care as found in Insurance Article, § 15-1009, Annotated Code of Maryland, for claims for members of the Plan; and

(h) An assurance that the administrator shall comply with any notice requirements specified by the Board in the request for proposals for the Plan Administrator.

E. Estimate of Total Charges for Administering the Plan. Each administrator that responds to a request for proposals to be the Plan Administrator shall provide, in the manner requested by the Board, an estimate of the total charges for administering the Plan.

F. Proven Ability to Apply Effective Cost Containment Programs.

(1) Each administrator that responds to a request for proposals to be the Plan Administrator shall provide to the Board:

(a) A description of each cost containment program that the administrator has available to use in the State; and

(b) An estimate of the savings that each cost containment program will provide to the Plan.

(2) Use of Private Review Agents. The Administrator shall provide to the Board an assurance that any utilization review performed for a member of the Plan shall be performed by a private review agent that has a certificate from the Commissioner to perform utilization review in the State.

G. Financial Condition and Stability of the Plan Administrator.

(1) A carrier shall be deemed to meet the financial condition and stability requirements for the Plan Administrator if the carrier is:

(a) An insurer with a certificate of authority in good standing to write health insurance in the State;

(b) A nonprofit health service plan with a certificate of authority in good standing to operate in the State; or

(c) A health maintenance organization with a certificate of authority in good standing to operate in the State.

(2) An administrator who is not a carrier shall:

(a) Be registered in the State as an administrator under Insurance Article, Title 8, Subtitle 3, Annotated Code of Maryland; and

(b) File with the Board the administrator's financial statements audited by an independent certified public accountant from the preceding two calendar years.

H. Provider Panel Requirements.

(1) A carrier shall provide evidence to the Board that it has procedures in place to comply with:

(a) The provider panel requirements of Insurance Article, §§ 15-112 and 15-115, Annotated Code of Maryland, for any provider panels used to provide health care services to Plan members;

(b) The compensation of health care practitioners requirements of Insurance Article, § 15-113, Annotated Code of Maryland, for services rendered to Plan members; and

(c) The uniform credentialing form requirements of Insurance Article, § 15-112.1, Annotated Code of Maryland, when credentialing providers for the Plan.

(2) An administrator that is not a carrier shall provide assurances to the Board that the administrator shall comply with:

(a) The provider panel requirements of Insurance Article, §§ 15-112 and 15-115, Annotated Code of Maryland, for any provider panels used to provide health care services to Plan members;

(b) The compensation of health care practitioners requirements of Insurance Article, § 15-113, Annotated Code of Maryland, for services rendered to Plan members; and

(c) The uniform credentialing form requirements of Insurance Article, § 15-112.1, Annotated Code of Maryland, when credentialing providers for the Plan.

I. Use of Standardized Forms.

(1) A carrier shall provide evidence to the Board that it has procedures in place to comply with the uniform consultation referral form requirements of Insurance Article, § 15-119, Annotated Code of Maryland and COMAR 31.10.12 for Plan member referrals.

(2) An administrator that is not a carrier shall provide written assurance to the Board that it will comply with the uniform consultation referral form requirements of Insurance Article, § 15-119, Annotated Code of Maryland and COMAR 31.10.12 for Plan member referrals.

Md. Code Regs. 31.17.01.03

Regulations .03 adopted as an emergency provision effective February 6, 2003 (30:5 Md. R. 365); adopted permanently effective August 4, 2003 (30:15 Md. R. 993)