EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*hb0912*
HOUSE BILL 912
J2, J5 2lr1985
HB 1165/20 – HGO CF SB 707
By: Delegate Sample–Hughes
Introduced and read first time: February 7, 2022
Assigned to: Health and Government Operations
A BILL ENTITLED
AN ACT concerning 1
Health Insurance – Provider Panels – Coverage for Nonparticipation 2
FOR the purpose of requiring each carrier to inform members and beneficiaries of the right 3
to request a referral to a specialist or nonphysician specialist who is not part of the 4
carrier’s provider panel; establishing certain requirements on certain insurers, 5
nonprofit health service plans, and health maintenance organizations related to the 6
coverage of certain mental health and substance use disorder services provided to a 7
member by a nonparticipating provider; requiring the Consumer Education and 8
Advocacy Program, in collaboration with the Health Education and Advocacy Unit 9
of the Office of the Attorney General, to provide public education to inform 10
consumers of certain rights; and generally relating to provider panels and coverage 11
for nonparticipating providers. 12
BY repealing and reenacting, with amendments, 13
Article – Health – General 14
Section 19–710(p) 15
Annotated Code of Maryland 16
(2019 Replacement Volume and 2021 Supplement) 17
BY repealing and reenacting, with amendments, 18
Article – Insurance 19
Section 15–830 20
Annotated Code of Maryland 21
(2017 Replacement Volume and 2021 Supplement) 22
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 23
That the Laws of Maryland read as follows: 24
Article – Health – General 25
19–710. 26 2 HOUSE BILL 912
(p) (1) Except as provided in paragraph (3) of this subsection, individual 1
enrollees and subscribers of health maintenance organizations issued certificates of 2
authority to operate in this State [shall] MAY not be liable to any health care provider for 3
any covered services provided to the enrollee or subscriber. 4
(2) (i) A health care provider or any representative of a health care 5
provider may not collect or attempt to collect from any subscriber or enrollee any money 6
owed to the health care provider by a health maintenance organization issued a certificate 7
of authority to operate in this State. 8
(ii) A health care provider or any representative of a health care 9
provider may not maintain any action against any subscriber or enrollee to collect or 10
attempt to collect any money owed to the health care provider by a health maintenance 11
organization issued a certificate of authority to operate in this State. 12
(3) Notwithstanding any other provision of this subsection, a health care 13
provider or representative of a health care provider may collect or attempt to collect from a 14
subscriber or enrollee: 15
(i) Any copayment or coinsurance sums owed by the subscriber or 16
enrollee to a health maintenance organization issued a certificate of authority to operate in 17
this State for covered services provided by the health care provider; 18
(ii) If Medicare is the primary insurer and a health maintenance 19
organization is the secondary insurer, any amount up to the Medicare approved or limiting 20
amount, as specified under the Social Security Act, that is not owed to the health care 21
provider by Medicare or the health maintenance organization after coordination of benefits 22
has been completed, for Medicare covered services provided to the subscriber or enrollee by 23
the health care provider; or 24
(iii) Any payment or charges for services that are not covered 25
services. 26
Article – Insurance 27
15–830. 28
(a) (1) In this section the following words have the meanings indicated. 29
(2) “Carrier” means: 30
(i) an insurer that offers health insurance other than long–term 31
care insurance or disability insurance; 32
(ii) a nonprofit health service plan; 33
HOUSE BILL 912 3
(iii) a health maintenance organization; 1
(iv) a dental plan organization; or 2
(v) except for a managed care organization as defined in Title 15, 3
Subtitle 1 of the Health – General Article, any other person that provides health benefit 4
plans subject to State regulation. 5
(3) (i) “Member” means an individual entitled to health care benefits 6
under a policy or plan issued or delivered in the State by a carrier. 7
(ii) “Member” includes a subscriber. 8
(4) “Nonphysician specialist” means a health care provider [who]: 9
(i) 1. WHO is not a physician; 10
[(ii)] 2. WHO is licensed or certified under the Health Occupations 11
Article; and 12
[(iii)] 3. WHO is certified or trained to treat or provide health care 13
services for a specified condition or disease in a manner that is within the scope of the 14
license or certification of the health care provider; OR 15
(II) THAT IS LICENSED AS A BEHAVIORAL HEALTH PROGRAM 16
UNDER § 7.5–401 OF THE HEALTH – GENERAL ARTICLE. 17
(5) (i) “Provider panel” means the providers that contract with a carrier 18
either directly or through a subcontracting entity to provide health care services to 19
enrollees of the carrier. 20
(ii) “Provider panel” does not include an arrangement in which any 21
provider may participate solely by contracting with the carrier to provide health care 22
services at a discounted fee–for–service rate. 23
(6) “Specialist” means a physician who is certified or trained to practice in 24
a specified field of medicine and who is not designated as a primary care provider by the 25
carrier. 26
(b) (1) Each carrier that does not allow direct access to specialists shall 27
establish and implement a procedure by which a member may receive a standing referral 28
to a specialist in accordance with this subsection. 29
(2) The procedure shall provide for a standing referral to a specialist if: 30
(i) the primary care physician of the member determines, in 31 4 HOUSE BILL 912
consultation with the specialist, that the member needs continuing care from the specialist; 1
(ii) the member has a condition or disease that: 2
1. is life threatening, degenerative, chronic, or disabling; and 3
2. requires specialized medical care; and 4
(iii) the specialist: 5
1. has expertise in treating the life –threatening, 6
degenerative, chronic, or disabling disease or condition; and 7
2. is part of the carrier’s provider panel. 8
(3) Except as provided in subsection (c) of this section, a standing referral 9
shall be made in accordance with a written treatment plan for a covered service developed 10
by: 11
(i) the primary care physician; 12
(ii) the specialist; and 13
(iii) the member. 14
(4) A treatment plan may: 15
(i) limit the number of visits to the specialist; 16
(ii) limit the period of time in which visits to the specialist are 17
authorized; and 18
(iii) require the specialist to communicate regularly with the primary 19
care physician regarding the treatment and health status of the member. 20
(5) The procedure by which a member may receive a standing referral to a 21
specialist may not include a requirement that a member see a provider in addition to the 22
primary care physician before the standing referral is granted. 23
(c) (1) Notwithstanding any other provision of this section, a member who is 24
pregnant shall receive a standing referral to an obstetrician in accordance with this 25
subsection. 26
(2) After the member who is pregnant receives a standing referral to an 27
obstetrician, the obstetrician is responsible for the primary management of the member’s 28
pregnancy, including the issuance of referrals in accordance with the carrier’s policies and 29
procedures, through the postpartum period. 30 HOUSE BILL 912 5
(3) A written treatment plan may not be required when a standing referral 1
is to an obstetrician under this subsection. 2
(d) (1) Each carrier shall establish and implement a procedure by which a 3
member may request a referral to a specialist or nonphysician specialist who is not part of 4
the carrier’s provider panel in accordance with this subsection. 5
(2) The procedure shall provide for a referral to a specialist or nonphysician 6
specialist who is not part of the carrier’s provider panel if: 7
(i) the member is diagnosed with a condition or disease that 8
requires specialized health care services or medical care; and 9
(ii) 1. the carrier does not have in its provider panel a specialist 10
or nonphysician specialist with the professional training and expertise to treat or provide 11
health care services for the condition or disease; or 12
2. the carrier cannot provide reasonable access to a specialist 13
or nonphysician specialist with the professional training and expertise to treat or provide 14
health care services for the condition or disease without unreasonable delay or travel. 15
(3) The procedure shall ensure that a request to obtain a referral to a 16
specialist or nonphysician specialist who is not part of the carrier’s provider panel is 17
addressed in a timely manner that is: 18
(i) appropriate for the member’s condition; and 19
(ii) in accordance with the timeliness requirements for 20
determinations made by private review agents under § 15–10B–06 of this title. 21
(4) The procedure may not be used by a carrier as a substitute for 22
establishing and maintaining a sufficient provider network in accordance with § 15–112 of 23
this title. 24
(5) Each carrier shall: 25
(i) have a system in place that documents all requests to obtain a 26
referral to receive a covered service from a specialist or nonphysician specialist who is not 27
part of the carrier’s provider panel; [and] 28
(II) INFORM MEMBERS AND B ENEFICIARIES, IN PLAIN 29
LANGUAGE, OF THE RIGHT TO REQU EST A REFERRAL UNDER PARAGRAPH (1) OF 30
THIS SUBSECTION IN P RINT AND ELECTRONIC PLAN DOCUMENTS AND A NY 31
PROVIDER DIRECTORY ; AND 32
6 HOUSE BILL 912
[(ii)] (III) provide the information documented under item (i) of this 1
paragraph to the Commissioner on request. 2
(e) (1) For purposes of calculating any deductible, copayment amount, or 3
coinsurance payable by the member, a carrier shall treat services received in accordance 4
with subsection (d) of this section as if the service was provided by a provider on the 5
carrier’s provider panel. 6
(2) ON REQUEST FOR AN IN –PERSON OR TELEHEALTH VISIT, IF THE 7
CARRIER’S PROVIDER PANEL HAS AN INSUFFICIENT NUMB ER OR TYPE OF 8
PARTICIPATING SPECIA LISTS OR NONPHYSICIA N SPECIALISTS WITH T HE EXPERTISE 9
TO PROVIDE THE COVER ED MENTAL HEALTH OR SUB STANCE USE DISORDER 10
SERVICES REQUIRED UN DER § 15–802 OR § 15–840 OF THIS SUBTITLE TO A MEMBER 11
WITHIN THE APPOINTME NT WAITING TIME OR T RAVEL DISTANCE STAND ARDS 12
ESTABLISHED IN REGUL ATIONS, THE CARRIER SHALL CO VER THE SERVICES 13
PROVIDED BY A NONPARTICIPATING P ROVIDER AT NO GREATE R COST TO THE 14
MEMBER THAN IF THE S ERVICES WERE PROVIDE D BY A PROVIDER ON T HE 15
CARRIER’S PROVIDER PANEL . 16
(3) EACH CARRIER SHALL US E THE REIMBURSEMENT RATE 17
ESTABLISHED UNDER PA RAGRAPH (4) OF THIS SUBSECTION T O: 18
(I) ENTER TIMELY SINGLE CASE AGREEMENTS ; AND 19
(II) PAY PROVIDERS . 20
(4) (I) SUBJECT TO SUBPARAGRA PH (II) OF THIS PARAGRAPH , AND 21
NOT LATER THAN JANUARY 1, 2023, THE MARYLAND HEALTH COMMISSION SHALL 22
ESTABLISH A REIMBURS EMENT FORMULA TO DET ERMINE THE REI MBURSEMENT 23
RATE FOR NONPARTICIP ATING PROVIDERS THAT DELIVER SERVICES UND ER 24
PARAGRAPH (2) OF THIS SUBSECTION . 25
(II) THE MARYLAND HEALTH COMMISSION SHALL HOLD 26
PUBLIC MEETINGS WITH CARRIERS, MENTAL HEALTH AND SU BSTANCE USE 27
DISORDER PROVIDERS , CONSUMERS OF MENTAL HEALTH AND SU BSTANCE USE 28
DISORDER SERVICES , AND OTHER INTERESTED PARTIES TO DETERMINE THE 29
REIMBURSEMENT FORMUL A. 30
(f) A decision by a carrier not to provide access to or coverage of treatment or 31
health care services by a specialist or nonphysician specialist in accordance with this 32
section constitutes an adverse decision as defined under Subtitle 10A of this title if the 33
decision is based on a finding that the proposed service is not medically necessary, 34
appropriate, or efficient. 35
HOUSE BILL 912 7
(g) (1) Each carrier shall file with the Commissioner a copy of each of the 1
procedures required under this section, including: 2
(i) steps the carrier requires of a member to request a referral; 3
(ii) the carrier’s timeline for decisions; and 4
(iii) the carrier’s grievance procedures for denials. 5
(2) Each carrier shall make a copy of each of the procedures filed under 6
paragraph (1) of this subsection available to its members: 7
(i) in the carrier’s online network directory required under § 8
15–112(n)(1) of this title; and 9
(ii) on request. 10
(H) THE CONSUMER EDUCATION AND ADVOCACY PROGRAM, ESTABLISHED 11
UNDER TITLE 2, SUBTITLE 3 OF THIS ARTICLE , IN COLLABORATION WIT H THE 12
HEALTH EDUCATION AND ADVOCACY UNIT OF THE OFFICE OF THE ATTORNEY 13
GENERAL, SHALL PROVIDE PU BLIC EDUCATION TO IN FORM CONSUMERS OF TH EIR 14
RIGHT TO REQUEST A R EFERRAL TO A SPECIAL IST OR NONPHYSICIAN SPECIALIST 15
AS PROVIDED FOR IN T HIS SECTION. 16
(I) THIS SECTION MAY NOT BE CONSTRUED TO LIMI T THE PROVISIONS IN § 17
19–710(P) OF THE HEALTH – GENERAL ARTICLE. 18
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 19
policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 20
after January 1, 2023. 21
SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 22
October 1, 2022. 23