EXPLANATION: CAPITALS INDICATE MATTER ADDE D TO EXISTING LAW .
[Brackets] indicate matter deleted from existing law.
*hb0675*
HOUSE BILL 675
J5, J4 2lr0887
CF 2lr2810
By: Delegates Hartman, Boteler, Chisholm, Hornberger, Krebs, Mangione,
McComas, Otto, Parrott, Reilly, Rose, Szeliga, and Thiam
Introduced and read first time: January 31, 2022
Assigned to: Health and Government Operations
A BILL ENTITLED
AN ACT concerning 1
Health Insurance – Changes to Coverage, Benefits, and Drug Formularies – 2
Timing 3
FOR the purpose of prohibiting certain insurers, nonprofit health service plans, and health 4
maintenance organizations from making changes to coverage, benefits, or drug 5
formularies under a health insurance policy or contract during the term of the health 6
insurance policy or contract; authorizing certain insurers, nonprofit health service 7
plans, and health maintenance organizations to make certain changes to coverage, 8
benefits, and drug formularies on renewal of a health insurance policy or contract; 9
and generally relating to health insurance and changes to coverage, benefits, and 10
drug formularies. 11
BY adding to 12
Article – Insurance 13
Section 15–146 14
Annotated Code of Maryland 15
(2017 Replacement Volume and 2021 Supplement) 16
BY repealing and reenacting, with amendments, 17
Article – Insurance 18
Section 15–831 19
Annotated Code of Maryland 20
(2017 Replacement Volume and 2021 Supplement) 21
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 22
That the Laws of Maryland read as follows: 23
Article – Insurance 24
2 HOUSE BILL 675
15–146. 1
(A) THIS SECTION APPLIES TO: 2
(1) INSURERS AND NONPROF IT HEALTH SERVICE PL ANS THAT 3
PROVIDE HOSPITAL , MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GR OUPS 4
ON AN EXPENSE –INCURRED BASIS UNDER HEALTH INSURANCE POL ICIES THAT ARE 5
ISSUED OR DELIVERE D IN THE STATE; 6
(2) HEALTH MAINTENANCE O RGANIZATIONS THAT PR OVIDE 7
HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GR OUPS UNDER 8
CONTRACTS THAT ARE I SSUED OR DELIVERED I N THE STATE; AND 9
(3) INSURERS, NONPROFIT HEALTH SER VICE PLANS, AND HEALT H 10
MAINTENANCE ORGANIZA TIONS THAT PROVIDE C OVERAGE FOR PRESCRIP TION 11
DRUGS THROUGH A PHAR MACY BENEFITS MANAGE R. 12
(B) NOTWITHSTANDING ANY O THER PROVISION OF LA W, AN ENTITY 13
SUBJECT TO THIS SECT ION: 14
(1) MAY NOT CHANGE THE COVERAGE OF SERVICES OR BENEFITS 15
PROVIDED UNDER A HEALTH INSURANCE POL ICY OR CONTRACT DURI NG THE TERM 16
OF THE POLICY OR CON TRACT; AND 17
(2) MAY CHANGE THE COVERAGE OF SERVICES OR BENEF ITS 18
PROVIDED UNDER A HEA LTH INSURANCE POLICY OR CONTRACT ON RENEWAL OF 19
THE POLICY OR CONTRA CT. 20
15–831. 21
(a) (1) In this section the following words have the meanings indicated. 22
(2) “Authorized prescriber” has the meaning stated in § 12–101 of the 23
Health Occupations Article. 24
(3) “Formulary” means a list of prescription drugs or devices that are 25
covered by an entity subject to this section. 26
(4) (i) “Member” means an individual entitled to health care benefits 27
for prescription drugs or devices under a policy issued or delivered in the State by an entity 28
subject to this section. 29
(ii) “Member” includes a subscriber. 30
(b) (1) This section applies to: 31 HOUSE BILL 675 3
(i) insurers and nonprofit health service plans that provide coverage 1
for prescription drugs and devices under individual, group, or blanket health insurance 2
policies or contracts that are issued or delivered in the State; and 3
(ii) health maintenance organizations that provide coverage for 4
prescription drugs and devices under individual or group contracts that are issued or 5
delivered in the State. 6
(2) An insurer, nonprofit health service plan, or health maintenance 7
organization that provides coverage for prescription drugs and devices through a pharmacy 8
benefits manager is subject to the requirements of this section. 9
(3) This section does not apply to a managed care organization as defined 10
in § 15–101 of the Health – General Article. 11
(c) Each entity subject to this section that limits its coverage of prescription drugs 12
or devices to those in a formulary shall establish and implement a procedure by which a 13
member may: 14
(1) receive a prescription drug or device that is not in the entity’s formulary 15
or has been removed from the entity’s formulary in accordance with this section; or 16
(2) continue the same cost sharing requirements if the entity has moved 17
the prescription drug or device to a higher deductible, copayment, or coinsurance tier. 18
(d) The procedure shall provide for coverage for a prescription drug or device in 19
accordance with subsection (c) of this section if, in the judgment of the authorized 20
prescriber: 21
(1) there is no equivalent prescription drug or device in the entity’s 22
formulary in a lower tier; 23
(2) an equivalent prescription drug or device in the entity’s formulary in a 24
lower tier: 25
(i) has been ineffective in treating the disease or condition of the 26
member; or 27
(ii) has caused or is likely to cause an adverse reaction or other harm 28
to the member; or 29
(3) for a contraceptive prescription drug or device, the prescription drug or 30
device that is not on the formulary is medically necessary for the member to adhere to the 31
appropriate use of the prescription drug or device. 32
4 HOUSE BILL 675
(e) A decision by an entity subject to this section not to provide access to or 1
coverage of a prescription drug or device in accordance with this section constitutes an 2
adverse decision as defined under Subtitle 10A of this title if the decision is based on a 3
finding that the proposed drug or device is not medically necessary, appropriate, or 4
efficient. 5
(f) (1) AN ENTITY SUBJECT TO THIS SECTION: 6
(I) MAY NOT REMOVE A DRUG FROM I TS FORMULARY OR MOVE 7
A PRESCRIPTION DRUG OR DEVICE TO A BENEF IT TIER THAT REQUIRE S A MEMBER 8
TO PAY A HIGHER DEDU CTIBLE, COPAYMENT , OR COINSURANCE AMOUN T FOR THE 9
PRESCRIPTION DRUG OR DEVICE DURING THE TERM OF A HEALTH INSURANCE 10
POLICY OR CONTRACT; AND 11
(II) MAY REMOVE A DRUG FR OM ITS FORMULARY OR MOVE A 12
PRESCRIPTION DRUG OR DEVICE TO A BENEFIT TIER THAT REQUIRES A MEMBER TO 13
PAY A HIGHER DEDUCTI BLE, COPAYMENT , OR COINSURANCE AMOUN T FOR THE 14
PRESCRIPTION DRUG OR DEVICE ON RENEWAL OF A HEALTH INSURANCE POLICY OR 15
CONTRACT. 16
(2) [An] ON RENEWAL OF A HEALT H INSURANCE POLICY O R 17
CONTRACT, AN entity subject to this section that removes a drug from its formulary or 18
moves a prescription drug or device to a benefit tier that requires a member to pay a higher 19
deductible, copayment, or coinsurance amount for the prescription drug or device shall 20
provide a member who is currently on the prescription drug or device and the member’s 21
health care provider with: 22
[(1)] (I) notice of the change at least 30 days before the change is 23
implemented; and 24
[(2)] (II) in the notice required under item [(1)] (I) of this [subsection] 25
PARAGRAPH , the process for requesting an exemption through the procedure adopted in 26
accordance with this section. 27
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 28
policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 29
after January 1, 2023. 30
SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 31
January 1, 2023. 32