Maryland Physicians Review Board
The mission of the Maryland Physicians Review Board for the state of Maryland protects the welfare of health consumers. The Board monitors the licensing of many clinical practitioners. The Medical Protection Act gives authority to the Maryland Board of Physicians investigative, and discipline physicians with strong sanctions for serious offenses. The board provides to the public licensing information related to sanctions, and licensing.
Complaints
Complaint means a written allegation that a physician committed a prohibited act. Complaints listed in the Medical Protection Act (a) Malpractice, (b) Report from a hospital or institution alleging violations of the Health Occupations Article (c) Malpractice insurance report (d) Law enforcement report (e) Report from anther country, state, or jurisdiction or the armed services (f) Consumer Complaints (g) Telephone directory (h) Advertisement (i) News article (j) media tape and (k) other. Serious offense complaints are misuse of alcohol and/or drugs leading to impaired judgment on the job (Maryland Medical Practice Act, 2002). Sexual contact with patients is a serious offense with separate policy for complaint processes. Any clinician convicted of a criminal nature results in discipline. Clinicians may not prescribe narcotics without a “bona fide” indication of need. Kickbacks of money or other for referral of patients, is a serious offense to providing quality care. No physician may practice without a license, or aiding others. Clinicians’ providing substandard care is the last serious complaint that results in investigation.
Minor complaints generally take a few weeks informally to investigate, and resolve. A disciplinary result for minor complaints is a letter of advisory “which informs, educates, or admonishes a health care provider in regard to the practice of medicine under (What is the Maryland board of physicians? 2003). Serious offenses resulting in investigation can take up to 18 months to complete. Cases involving standards of quality care go through peer review.
Breach
The board must show evidence to justify the breach of the Maryland Medical Protection Act. Complaint determination follows several steps. First, dismissal of charges occur when the claim lacks evidence If the evidence supports the claim the board makes a determination to take informal action, by first issuing the advisory letter.
In the letter, the board could request the respondent to enter into a disposition agreement with the board. The board can issue a cease and desist order regarding the complaint. The board can deny licensure, reinstatement, and accept surrender.
For serious complaints, the board can vote to charge the physician with violation of the Medical Protection Act. The board forwards the information for prosecutorial action. The prosecutor may send the case back based on the evidence. If the board issues charges or a notice of intent to deny licensure the board will offer the opportunity for the alleged offender to request a Case Resolution Conference unless a lack of response or intent to deny.
The Case Resolution Conference is voluntary, informal, and confidential. If both parties are unable to reach, an agreement the case proceeds to a hearing. The alleged offender can request a conference to issue formal charges.
The Administrative Procedure Act governs hearings of the board (Maryland Medical Protection Act, 2002). Due process allows the accused to defend himself before an administrative law judge in a formal administrative hearing. The complainant is a witness in formal proceedings. Sensitive cases allow the witness identity to remain confidential. After the hearing confirms breach, disciplinary actions follow concluding the Case Resolution Conference.
Disciplinary Action
The board allows disciplinary penalty appropriate to the complaint. This includes “retraining, a course in ethics, psychiatric treatment community services, in addition to or in lieu of suspension or revocation” (Maryland Medical Protection Act, 2002). Board has authority to reprimand, suspend, deny or surrender license, dismiss the charges. Factors taken in consideration include financial benefits from the conduct, willfulness of improper conduct, extent of actual, or potential harm caused to the public, The Maryland Medical Protection Act lists the following penalties: First time offender’s penalties are between (a) $1000.00 and not more than $30,000.00. The second offense, the penalty is (b) less than $10,000.00 and up to $40,000.00, the third offense minimum is (c) $15,000.00 and maximum of $50,000.00 (2002).
Example
According to Barrett, Neil Solomon the former Maryland Secretary of Health surrendered his medical license (2005). The letter was an admission to his misconduct (Appendix 1). While working at a weight-loss center the physician had sexual relationships with eight female patients. This former physician did not do this to the staff, but rather the patients. The women sued for $160 million forcing the physician into bankruptcy. He paid a total of $45,000.00. Part of the surrender process is admission of misconduct. The Maryland Board of Physicians according to Barrett, The board warned if he denied any details, the board would release the details of the investigation (2005).
Conclusion
Board cannot order compensation to an individual harmed by a physician civil matter. Findings from the board are inadmissible in civil actions. The civil action may not include information related to the criminal case. The act of the suit requires examination. The information within the Case Resolution Conference is inadmissible unless the information comes from another source. A motion for reconsideration is at the discretion of the board. The board does not automatically give a right to reconsideration. A judicial review of the board’s decision is an option the physician can pursue. If the board denies reinstatement, the physician has the option for appealing the decision in a judicial review as well.
References
Maryland Medical Practice Act (2002) Code of Maryland Regulations, and Register: 10.32.02.02 of Maryland Retrieved on February 14, 2010 from Division of State Documents: http://www.dsd.state.md.us/comar/comarhtml/10/10.32.02.02.htm
What is the Maryland Board of Physicians? (2003) Board of Physicians, Maryland Department of Health And Human and Mental Hygiene Retrieved on February 14, 2010 from http://www.mbp.state.md.us/pages/whatis.html
Barrett, Stephen (2005). Former Maryland Secretary of Health Surrenders Medical License. Retrieved on February 14, 2010 from Casewatch.org http://www.casewatch.org/board/med/solomon.shtml
Appendix 1
NEIL SOLOMON, M.D.
901 Dulaney Valley Road
Dulaney Center 2
Towson, Maryland 21204
October 27, 1993
State of Maryland Board of Physician Quality Assurance
4201 Patterson Avenue
P.O. Box 2571
Baltimore, Maryland 21215-0095
Re: Surrender of Medical License of Neil Solomon, M.D.
License Number: D 12963
Case Number: 94-0104, 94-0105
Dear Mr. Gunther and Members of the Board:
Please be advised that I have decided to surrender my license to practice medicine in the State of Maryland, License Number D12963. I understand that I may not give medical advice or treatment to any individual, with or without compensation, cannot prescribe medications, or otherwise engage in the practice of medicine as it is defined in Md. Health Occ. Code Ann. §14-101 (1991 Replacement Volume). In other words, I understand that surrender of my license means that I am in the same position as an unlicensed individual.
I understand that this letter of surrender shall be considered a PUBLIC document immediately upon its acceptance by the Board of Physician Quality Assurance (the "Board”). I also understand that this surrender of my medical license is and shall be considered IRREVOCABLE.
My decision to surrender my license to practice medicine has been prompted by an investigation of my practice by the Board. The Board initiated this investigation after it received several complaints, and after it became aware of several civil actions filed against me by former patients, all of which alleged that I instigated improper sexual contact with patients during the physician/patient relationship.
I admit that for at least the past 20 years, I have used my position as a physician to instigate a wide range of sexual relations with at least eight women patients. This conduct included acts of sexual intercourse, as well as other explicit sex acts. These activities took place in my medical office during patient visits, as well as in other locations. I admit that I engaged in sexual misconduct with my patients during the physician/patient relationship. I admit that I engaged in this conduct with multiple patients over the same time period. I recognize that these patients developed a sense of trust, confidence, and dependence through the physician/patient relationship, and that I misused my influence as a physician and the trust my patients placed in me for my own sexual gratification.
I admit that it was improper to engage in any sexual relationship with any patient.
The Board's investigation resulted in charges under the Maryland Medical Practice Act (the "Act"). Specifically, the Board, on October 13, 1993, voted to charge me with the commission of certain prohibited acts under Md. Health Occ. Code Ann. ("H.O") §14-404, including the following:
Subject to the hearing provisions of §14-405 of this subtitle, the Board, on the affirmative vote of a majority of its full authorized membership, may reprimand and licensee, place a licensee on probation, or suspend or revoke a license if the licensee: l a guilty of immoral or unprofessional conduct in the practice of medicine; [H.O. §14-404(a) (3) I.
Furthermore, pursuant to State Gov't Code Ann. §10-226, the Board, on October 13, 1993, voted to consider SUMMARILY SUSPENDING my license to practice medicine in the State of Maryland.
On October 20, 1993, my attorney was personally served with an unexecuted copy of a proposed Order for Summary Suspension of my medical license, issued by the Board, which specified the charges in particularized detail. I affirm that I have received a copy of the unexecuted Order for Summary Suspension, and have otherwise been advised of the Board's actions through, communications between representatives of the Office of the Attorney General and my legal counsel.
I have decided to surrender my license to practice medicine in the State of Maryland and in all other states where I maintain a license in lieu of summary suspension and revocation of my license by the Board.
I understand that pursuant to its authority under Md. Health Occ. Code Ann. §14-403, the Board has the authority to set conditions on its agreement to accept the surrender of my medical license. In addition to the above, I understand that as a condition of the Board's acceptance of this Letter of Surrender, I agree to the following:
1. Within seven days of the acceptance of this Letter of Surrender by the Board, I will submit irrevocable letters of surrender of my medical license to any other states, jurisdictions, or countries where I have a medical license, or have any applications for licensure pending. In these irrevocable Letters of Surrender, I will fully advise the respective medical boards of the actions taken by the State of Maryland, and the basis of those actions. I agree to attach to those letters this Letter of Surrender. I agree to submit to the Board within thirty (30) days of the acceptance of this Letter of Surrender, proof it deems satisfactory that I have complied with this condition;
2. I will not under any circumstances apply for a medical license or a reinstatement of my medical license in the State of Maryland or in any other state, jurisdiction, or country;
3. In the event that I apply for reinstatement of my medical license in Maryland or in any other state, jurisdiction, or country, the Board, in its sole discretion, may publicly release any and all information regarding the findings of its investigation into my conduct as a physician and my medical practice that would otherwise be confidential under applicable laws, including, but not limited to the unexecuted Order for Summary Suspension;
4. In the event that I make any public statements denying my unprofessional sexual misconduct with my patients, the Board, in its sole discretion, may publicly release any and all information regarding the findings of its investigation into my conduct as a physician and my medical practice that would otherwise be confidential under applicable laws, including, but not limited to the unexecuted Order for Summary Suspension.
I understand and agree that the Board will advise the Federation of State Medical Boards and the National Practitioners Data Bank of this Letter of Surrender, and that1 surrendered by medical licensee in lieu of a summary suspension and a revocation of my medical licensure by the Board. I affirm that I am also currently licensed to practice medicine in the District of Columbia, and in the States of New York and Ohio. I acknowledge that on the date Board accepts this Letter of Surrender, the Board Mr. Gunther and Members of the Board will send copies of this document to the respective medical boards of those jurisdictions.I affirm that I have a current Maryland Controlled Dangerous Substances Registration Certificate M07437 issued by the Maryland Division of Drug Control; and that I have a current United States Drug Enforcement Administration ("DEA") Certificate for the State of Maryland, Certificate AS2376689, issued by the DEA.I acknowledge that, on the date the Board accepts this Letter of Surrender, I must present to the Board:
1. Maryland License D12963, including any renewal certificates and wallet-sized renewal cards;
2. Maryland Controlled Dangerous Substances Certificate Number M07437 including any prescription pads bearing my name and any prescription ordering forms in my possession or under my control; and
3. United States DEA registration Certificate AS2376689 I acknowledge that on the date that the Board accepts this Letter of Surrender, the Board will send a copy of this Letter of Surrender to both the State of Maryland Division of Drug Control and the United States DEA, attesting that I am surrendering my privilege to prescribe controlled dangerous substances in the State of Maryland. I further acknowledge that I will submit a signed, executed copy of DEA form 104, Voluntary Surrender of Controlled Substances Privileges, which will be forwarded to the United States DEA.
Finally, I wish to make clear that I have consulted with an attorney before signing this letter IRREVOCABLY SURRENDERING my license to practice medicine in the State of Maryland. I understand both the nature of the Board's actions and this Letter of Surrender fully. I make this decision knowingly and voluntarily.
Sincerely,
_______________________
Neil Solomon, M.D.
VERIFICATION
I HEREBY CERTIFY that on this day of, 1993. before me, a Notary Public of the State of and City/County aforesaid, personally appeared Neil Solomon, M.D., and declared and affirmed under the penalties of perjury that signing the aforegoing Irrevocable Letter of Surrender was his voluntary act and deed.
Notary Public
My Commission Expires: 8/1/94
On behalf of the Boar of Physician Quality Assurance, on this 27th day of October 1993, I accept Neil Solomon, M.D.'s PUBLIC IRREVOCABLE surrender of his license to practice medicine in the State of Maryland.
_______________________
Frank A. Gunther, Jr., Vice Chair
Board of Physician Quality Assurance
Title 1 Protections and standards for qualified health benefits plans Section 101 Requirements Reforming Health Insurance Market Place The purpose of this title is to establish standards to ensure that new health insurance coverage and employments based health plans that are offered meet standards guaranteeing access to affordable coverage, essential benefits, and other consumer protections. Requirements for qualified health benefits plans On or after the first day of Y1, a health benefit plan shall not be a qualified health benefits plan under this division unless the plan meets the applicable requirements of the following for the types of plan and plan year involved Subtitle B- relating to affordable coverage “ C- Relating to essential benefits “ C- Relating to consumer protection Protecting the choice to keep current coverage- grandfathered in if the following are met 1. Limitations on new enrollment A. Except as provided in the paragraph insurance company offers coverage and does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1 B. B. Dependent coverage permitted not effect enrollment 2. Limits on changes in terms or conditions except as required under state law the issuer does not change including benefits, and cost sharing. 3. Restrictions on Premium Increases b. Cannot vary the percentage increase in premiums for a risk group grandfathered in without changing premiums for all enrollees in the risk group at the same rate 1. Grace period of current employment based health plans A. Grace Period beginning with Y1 for a 5-year period. Employment plan in operation the day of before the first day of Y1. B. Exception for limited benefits plan shall not apply to employment based plans that coverage consists of o American Recovery and Reinvestment Act of 2009 o Benefits from Employee Retirement Income Security Act of 1974 o Limitation supplied from insurance commissioner Employee-based health in no case shall consist of only one or more of the coverage benefits, through the The acts listed above. 2. Transitional treatment as acceptable coverage Grace period specified above described, is treated as acceptable coverage. C. Limitations on individual health insurance coverage 1. General a. Coverage not grandfathered in may be offered on or after the first day of Y1 as an exchange participating health plan. 2 Separate, accepted coverage permitted Nothing shall be permitted other than Para 1 other than the health insurance exchange, unless it is offered and priced separately from health insurance coverage. 2. Stand-alone dental and vision coverage a. Does not prevent offering stand-alone plans b. Benefits plans to such stand-alone plans offered and priced separately from the plan. Standards guaranteeing access to affordable coverage Prohibiting Preexisting Condition Exclusions No preexisting condition exclusion or impose any limit or condition on coverage with respect to an individual or dependent. Guaranteed Issue and Renewal for insured plans Applies to individuals and employees in individual and group health plan, whether offered in the Health Insurance Exchange through employment, or otherwise, and apply to the public health insurance plan option. Coverage offered in the small group market except renewal, or discontinuation. The issuer provides the enrollee with notice of non-payment, and a grace period to correct nonpayment except in cases of fraud. Insurance Rating Rules Guaranteed availability and renewability of coverage applies to individuals and employers in all individual and group coverage weather offered through the health insurance exchange, employment based, or otherwise and apply to the public health insurance option, (except renewal or discontinuation of coverage). Coverage is only prohibited in cases of fraud. A. a. Rates charged and coverage may not vary except: 1. Limited age variations 2. By area 3. By family enrollment b Actuarial value of optional service coverage 1. Commissioner will estimate the basic per enrollee, per month cost; determine an average actuarial base, to include coverage under a basic plan. 2. Considerations a. Take into account the impact of overall costs of inclusion of coverage, not any reduction of cost estimated with results from services, including prenatal, delivery, and postnatal care. b. B estimate costs as if coverage for the entire population and c. May not estimate cost at less than $1 per enrollee per month. C Study and Reports 1 The commissioner and Secretary of HHS and Sec. Of labor, conduct a study of large group insured and self-insured employer care markets to examine a. Types of employers by key characteristics: including size that purchase insured products v. self-insured. b. Note similarities and differences between typical insured, and self-plans c. Financial solvency and capital reserve levels of employers that self-insure by size d. Risk of self-insured employers unable to pay, or become insolvent as a result. e. Which rating rules likely to cause adverse selection in the large market or encourage small to midsize employers to self-insure 2 Reports Not later than 18 months after the enactment of the Act, the study will be submitted to Congress and agencies 1. Including a. Recommendations b. Ensure the law does not provide incentives for small and mid-size employers to self-insure or create adverse selection in risk pools of large groups, and self-insured employers. c. Not later than 18 months after the first day of Y1, for the Commissioner to submit to congress, and agencies i. Any updated reports, ii. Any updated recommendations Sect. 114. Nondiscrimination in Benefits; Parity in Mental Health and Substance Abuse Disorder Benefits. A. Plan shall prohibit discrimination, or benefit structure for plans from : • Employee Retirement Income Security Act of 1974 • The Public Health Service Act, and • IRS code of 1986. B. Parity in mental health and substance abuse disorder benefits a. Provisions are not superseded by or inconsistent with subtitle C, the provisions of section 2715, of the Public Health Service Act will apply to plans regardless of it being offered in individual or group market, such provisions apply coverage in the large group market. Sec 115. Ensuring Adequacy of Provider Networks a. Qualified health benefits plan that uses a network for items and services meet standards the Commissioner established for adequate networks with enrollee access to such items and services and transparency in the cost sharing differentials between in and out of network coverage. b. Provider network defined a) Means the provider which covered benefits treatments, and services are available under the plan Sec, 116 Ensuring value, and lower premiums a. Plans must meet a medical loss ratio. For any plan year in which the plan does not meet the medical loss ratio the entity shall provide rebates to enrollees of payment sufficient to meet the loss. b. Building on Interims Rules a. Building on the HHS the Commissioner will define and develop methodologies to determine how to calculate the medical loss ratio. Methodology will be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by qualify health benefits plan (QHBP) offering entities, competition in the insurance market in and out of the Exchange, and value for consumers so premiums are used for services. Subtitle C- Standards Guaranteeing Access to Essential Benefits Section 121 Coverage of Essential Benefits Package a. meets the standards adopted under section 124 for the essential benefits package described in section 122 for the plan year b. Choice of Coverage 1. Non exchange participating Health Benefits plans- 2. A plan not in an exchange participating plan, this type of plan may offer coverage in addition to the essential package. 3. Continuation of Offering of Separate excepted benefits coverage- Nothing in this section will affect the offering of benefits as excepted benefits, if offered under a separate policy, contract, or certificate of insurance. c. No Restrictions on Coverage Unrelated to clinical appropriateness- plan may not impose restrictions unrelated to clinical appropriateness on care of items and services Sect. 122 Essential benefits package defined a) Essential benefits package means health benefits coverage, consistent with standards adopted to ensure quality care, and financial security, that- 1. Provides payment for items and services b) Within the standards of care or practice 2. Limits cost sharing 3. Prohibits annual or lifetime limits on coverage 4. Complies with section 115 and 5. Is equivalent to the average employee sponsored coverage b. Minimum Services to be Covered-subject to subsection (d), the items, and services described are: 1. Hospitalization 2. Outpatient hospital and outpatient clinic, services, including emergency department services 3. Professional services of physicians and other health professionals 4. Services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, dr. offices patient homes, place of residence or other settings as appropriated. 5. Prescription Drugs 6. Rehabilitative and habilitative services 7. Mental Health and substance use disorder services, including behavior health treatment. 8. Preventive services including services a, or b by the task force on clinical preventive services and vaccines recommended by the CDC 9. Maternity care 10. Well baby and well childcare; treatment of congenital or developmental deformity, disease or injury; oral health, and hearing services, equipment and supplies for children under 21. c. Requirements relating to Cost-Sharing and Minimum Actuarial value 1. No cost sharing for preventive services. No cost sharing for essential benefits package for preventive items and services including well baby and well childcare. 2. Annual Limitation A does not exceed the applicable level specified under subparagraph b. B applicable Level Applicable level is for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increase in $100 increments for each subsequent year by annual percentage increase in the Consumer Price Index applicable to the year. C Use of copayments Use copayments not coinsurance 3. Minimum Actuarial Value a. provide a level of coverage designed to provide benefits that are equivalent to approx. 70% of the full actuarial value of the benefits. b. Reference benefits package described is essential benefits package if there were no cost sharing imposed. d. Abortion coverage prohibited as part of the Minimal, Benefits package 2. voluntary choice of coverage by plan. Plan is not required to provide coverage of services for paragraph 4a, or 4b and shall determine whether coverage is provided. 3. coverage under public health insurance option Provide coverage for services described in 4 b. Nothing shall be construed as preventing the public health insurance option from providing for or prohibiting coverage of services described in 4a. 4. Abortion Services A Abortions for which public funding is prohibited. Based on the law as in effect as of the date that is six months before the beginning of the plan year involved. B. Abortions for which public funding is allowed. The services for abortions which the expenditure of Federal funds appropriated for the DHH is permitted based on the law in effect as of the plan year involved. e. standalone coverage 1. No application to adult coverage- Nothing in this subtitle shall be construed as requiring an individual 21 or older to be provided stand-alone dental only or vision only coverage. 2. Treatment of combined coverage-The combination of stand-alone coverage described in paragraph 1 and a benefits plan without coverage of such oral and vision services shall be treated as satisfying the essential benefits package under this division. Sec. 123. Health Benefits Advisory Committee. A Establishment 1. establish a private-public advisory committee shall be a panel of medical and other experts to be known as the Health Benefits Advisory Committee to recommend covered benefits, and essential, enhanced, and premium plans. 2. Chair- The Surgeon General shall be a Chair of the Health Benefits Advisory Committee. 3. Membership- The Health Benefits Advisory Committee shall be composed of the following members in addition to the surgeon general: a- Nine members who are not Federal employees or officers and who are appointed by the President. B nine members who are not federal employees or officers and who are appointed by the Comptroller General of the United States in a manner similar to the manner in which the Comptroller General appoints members to the Medicare Payment Advisory Commission under the Social Security Act. C. Such even number of members who are federal employees and officers as the President may appoint, not to exceed 8. Such initial appointments shall be made no later than 60 days after the date of the enactment of this Act. 4. Terms- Each member of the Committee shall serve a 3-year term on the Committee, except that the terms of the initial members shall be adjusted in order to provide for staggered tem of appointment for all such members. 5. Participation – The membership of the Committee shall at least reflect providers, consumer representatives, employers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities representatives of relevant governmental agencies, and at least one practicing physicians or other health professional and an expert on children’s health and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendation of such Committee. Not less than 25 percent of the members of the Committee shall be practicing health care practitioners, who as of the date of their appointment, practice in a rural area and who have practiced in a rural area for at least the 5-year period preceding such date. B Duties 1. Recommendations on benefits standards. The Health Benefits Advisory Committee shall recommend to the SHH benefit standard (4), and periodic updates to such standards. In developing such recommendations, the Committee shall take into account innovation in health care and consider how such standards could reduce health disparities. 2. Deadline- The Health Benefits Advisory Committee shall recommend initial benefits standards to the Secretary not later than 1 year after the date of the enactment of this Act. 3. Public Input- The Committee shall allow for public input when developing recommendations. 4. Benefit standards defined A the essential benefits package described in section 122, including treatment, items, and services within benefit classes, and cost-sharing consistent with (d) and B The cost sharing levels for enhanced plans and premium plans. 5. Levels of cost sharing for enhanced and Premium Plans A enhanced plan- the level of cost sharing for enhanced plans shall be designed so the plans have benefits that are actuarially equivalent to approximately 85% of the actuarial value of the benefits provided under the reference benefits package described in section 122© (3)(B) B. Premium Plan- The level of cost sharing for this plan is designed to have benefits that are actuarially equivalent approximately 95% of the actuarial value of the benefits provided under the reference benefits package. C Operations- 1. Per Diem Pay Each member shall receive travel expenses, including per diem in accordance with applicable provisions under subchapter I of chapter 57 of title 5, US Code and shall otherwise serve without additional pay. 2. Members not treated as Federal Employees. Members shall not be considered employees of the federal government by reason of any service on the committee. 3. Application of FACA The Federal Advisory Committee Act other than section 14 shall apply to the committee. d. Publication The secretary will provide in the Federal Register and post on the website of DHHS of all recommendations made. Sec. 124 Process for adoption of Recommendation Adoption of Benefit Standards. (a) Process for Adoption of Recommendations.- 1. Review of Recommended Standards.- Not later than 45 days after the date of receipt of benefits of such standards as modified under (2) (b), The Secretary will review standards and determine to propose adoption of as a package. 2. Determination to Adopt Standards If the Secretary determines- A to propose adoption of standards so recommended as a package, the Secretary shall propose adoption such standards or B not to propose adoption of such standards as a package, the Secretary shall notify the Committee in writing the determination and reasons for not proposing the recommendation and provide the Committee with opportunities to modify the recommendation and resubmit on a timely basis. 3. Contingency- If because the application of paragraph (2)(b), the Secretary would otherwise be unable to propose initial adoption of such recommended standards by the deadline The Secretary will propose adoption of the initial standards by such deadline. 4. Publication- In the Federal Register by the Secretary B adoption of Standards 1. Initial Standards not later than 18 months after the enactment date. The secretary through rule making process adopt an initial set of standards. 2. Periodic Updating Standards Under subsection a secretary will provide periodic updating the standards previously adoption. 3. Requirement- The Secretary may not adopt any standards for essential benefits or for level of cost sharing that are inconsistent with the requirements. Sec. 124. Process For Adoption of Benefit Standards A process for adoption of Recommendations 1 Review of recommended standards Not later than 45 days after the date of receipt of standards recommended under section of 123, the Secretary will review, and determine to propose adoption of standards as a package. 2. Determination to adopt standards If the secretary determines- A to propose adoption of standards as a package propose adoption or B not to propose adoption, the secretary shall notify the Committee of the determination and reasons. The secretary will provide an opportunity to modify and resubmit. 3. Contingency- If the application of (2) (B) the secretary would otherwise be unable to propose initial adoption of such recommended standards by the deadline 4. Publication- Secretary will publish in the Federal Register B Adoption of standards 1 initial standards not later than 18 months after the date of enactment, the secretary through rulemaking, adopt an initial set of standards 2. Periodic Updating Standards- the secretary will provide for periodic updating of the standards previously adopted. 3. Requirement- The secretary may not adopt any standards for an essential benefits package or for level of cost sharing that are inconsistent with the requirements for such a packs or level. Sec. 125 Prohibition of Discrimination In Health Care Services Based on Religious or Spiritual Content Neither the commissioner nor issuer discriminate in approving covering health care services on the basis of its religious or spiritual content if expenditures for such care are allowable as a deduction. Subtitle D- Additional Consumer Protections Sec. 131 Requiring Fair marketing practices by insurers. 132 Requiring fair grievance and appeals mechanism Section 133 Requiring information Transparency and Plan Disclosure A accurate and timely disclosure 1. plans shall comply with standards by the commissioner for the accurate and timely disclosure of plan documents, plan terms, and conditions, claims payment policies and practices, periodic financial disclosure, data on enrollment, data on disenrollment’s, data on the number of claims denials, data on rating practices, information on cost-sharing and payments with respect to any out of network coverage, and other info. As determined appropriate by the Commissioner, who shall require such disclosure be provided in plain language. 2. Plain Language- Means nonprofessionals language 3. Guidance – development and issue guidance on best practice in plain language. B Contracting Reimbursement- a qualified plan shall comply with standards by the commissioner to ensure transparency to each healthcare provider relating to reimbursement arrangements between such plan and such provider C Advance notice of plan changes- Shall not be made without reasonable notification and timely. D Pharmacy Benefit Managers Transparency Requirements pg44
