CurrentBlue Cross Blue Shield - MarylandPolicy 11.01.02

MDH Healthcare System Governing Body Policy

Establishes the structure, membership, roles, meeting rules, and bylaws for the Maryland Department of Health Healthcare System (HCS) Governing Body, applying to the eleven MDH-operated facilities and hospitals and MDH leadership involved in system governance.

Policy Summary

PayerBlue Cross Blue Shield - Maryland

PolicyMDH Healthcare System Governing Body Policy

Policy CodePolicy 11.01.02

Change TypeNo material changes

Effective DateApr 14, 2026

Next Review DateApr 14, 2029

Key ActionGoverning Body votes to adopt system-wide policies which are then advanced to the Secretary for final approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13voting members

11HCS facilities

9quorum

monthlymeeting cadence

Jan 9, 2026bylaws ratified

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Governing Body Operational Criteria

Key governance rules and operational requirements established by the policy:

Chair is the MDH HCS Director; Deputy Director serves as Co-Chair.

Governing Body composition: 13 voting members (MDH HCS Director, Deputy Director, and eleven facility/hospital CEOs or designees).

Quorum of 9 required; decisions by simple majority; votes recorded as counts (names not generally recorded unless motion adopted).

Meetings generally monthly and at least quarterly; Chair may call special meetings; meeting procedures align with the Governing Body bylaws and support administrative recordkeeping for transparency and survey readiness; meeting notes drafted and posted as draft within 10 days.

All Governing Body ratified policies are subject to final approval, veto, or modification by the Secretary of Health who retains ultimate authority.

Bylaws govern organizational structure, quorum, voting procedures, ex-officio roles, meeting protocols, and administrative recordkeeping; bylaws were ratified (January 9, 2026) and are subject to amendment by the Governing Body.

Facility-level responsibilities, including credentialing and privileging, remain with each hospital/facility; the Governing Body may review or coordinate system-wide quality improvement processes but does not supplant local operational authority except for system-wide matters.

Facility and hospital CEOs may appoint formal designees or proxies to attend and vote on their behalf to ensure representation when necessary.

Executive Assistant or administrative support is responsible for preparing the agenda, computing and recording quorum and attendance, taking meeting notes, and posting draft meeting notes in a timely manner to support transparency and survey readiness.

Decision and Meeting Rules — Actions and Governance Flow

Prior Authorization

Governing Body voting, quorum, meeting cadence, and Secretary review

The Governing Body must vote to adopt system‑wide policies; those adopted policies are forwarded to the Secretary of Health for final approval and remain subject to the Secretary’s authority to veto or modify. The Chair (Director, MDH HCS) may call special meetings as needed; meetings are generally monthly and at least quarterly. A quorum of nine of the 13 voting members is required for action; votes are by simple majority and are ordinarily held in person, though virtual voting is allowed for time‑sensitive matters.

Adopted system‑wide policies are advanced to the Secretary and are subject to the Secretary’s veto or final decision. (Source supports finality of action and Secretary authority.)
Chair (Director, MDH HCS) may call special meetings; notification provided via email. (Source supports Chair authority and special meeting notice.)
Meeting cadence: generally monthly and no less than quarterly. (Source: meeting frequency.)
Quorum: nine of 13 voting members required; decisions by simple majority. (Source: quorum & voting procedures.)
Voting modality: generally in‑person; virtual voting permitted for time‑sensitive situations. (Source: voting modality guidance.)

Key Definitions

Governing Body

Definition'Governing Body' means the deliberative leadership forum established to provide oversight, to ratify policies on a system-wide basis for the HCS and to advise MDH leadership on final decisions applicable to the HCS.

Primary FunctionsProvide system-wide oversight, ratify policies for the MDH Healthcare System, and advise MDH leadership on decisions affecting the HCS.

ScopeApplies to governance and policy matters that affect all MDH Healthcare System facilities and hospitals.

MDH Healthcare System (HCS)

Definition'MDH Healthcare System (HCS)' means the eleven MDH-operated facilities and hospitals, including five adult psychiatric hospitals, two child/adolescent residential treatment centers, two chronic care hospitals, and two Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) residential centers.

Number of FacilitiesEleven MDH-operated facilities and hospitals.

Facility TypesIncludes adult psychiatric hospitals, child/adolescent residential treatment centers, chronic care hospitals, and ICF/IID residential centers.

Ratification

Definition'Ratification' means the formal process by which the Governing Body votes to adopt a standard or policy before it is advanced to the Secretary for final approval or administrative filing.

Process OutcomeOnce ratified by the Governing Body, policies are advanced to the Secretary for final approval, veto, or modification.

Scope of UseUsed for adoption of system-wide standards and policies applicable across the MDH HCS.

Policy Dates and Ratification

2026-01-09bylaws_ratified

Governing Body bylaws were ratified (establishing organizational structure, quorum, voting procedures, and administrative recordkeeping).

2026-04-14policy_effectiveLatest

MDH policy 11.01.02 establishing the HCS Governing Body structure, meeting rules, and bylaws became effective.