EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
Underlining indicates amendments to bill.
Strike out indicates matter stricken from the bill by amendment or deleted from the law by
amendment.
*hb0912*
HOUSE BILL 912
J2, J5 2lr1985
HB 1165/20 – HGO CF SB 707
By: Delegate Sample–Hughes Delegates Sample–Hughes, Bagnall, Belcastro,
Bhandari, Carr, Chisholm, Cullison, Hill, Johnson, Kaiser, Kelly, Kerr,
Kipke, Landis, R. Lewis, Morgan, Reilly, Rosenberg, Saab, Szeliga, and
K. Young
Introduced and read first time: February 7, 2022
Assigned to: Health and Government Operations
Committee Report: Favorable with amendments
House action: Adopted
Read second time: March 10, 2022
CHAPTER ______
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
procedure to request a referral to a specialist or nonphysician specialist who is not 4
part of the carrier’s provider panel; establishing a certain requirements requirement 5
on certain insurers, nonprofit health service plans, and health maintenance 6
organizations related to the coverage provision of certain mental health and 7
substance use disorder services provided to a member by a nonparticipating 8
provider; requiring the Consumer Education and Advocacy Program, in collaboration 9
with the Health Education and Advocacy Unit of the Office of the Attorney General, 10
to provide public education to inform consumers of certain rights procedures; and 11
generally relating to provider panels and coverage 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 2 HOUSE BILL 912
Annotated Code of Maryland 1
(2017 Replacement Volume and 2021 Supplement) 2
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 3
That the Laws of Maryland read as follows: 4
Article – Health – General 5
19–710. 6
(p) (1) Except as provided in paragraph (3) of this subsection, individual 7
enrollees and subscribers of health maintenance organizations issued certificates of 8
authority to operate in this State [shall] MAY not be liable to any health care provider for 9
any covered services provided to the enrollee or subscriber. 10
(2) (i) A health care provider or any representative of a health care 11
provider may not collect or attempt to collect from any subscriber or enrollee any money 12
owed to the health care provider by a health maintenance organization issued a certificate 13
of authority to operate in this State. 14
(ii) A health care provider or any representative of a health care 15
provider may not maintain any action against any subscriber or enrollee to collect or 16
attempt to collect any money owed to the health care provider by a health maintenance 17
organization issued a certificate of authority to operate in this State. 18
(3) Notwithstanding any other provision of this subsection, a health care 19
provider or representative of a health care provider may collect or attempt to collect from a 20
subscriber or enrollee: 21
(i) Any copayment or coinsurance sums owed by the subscriber or 22
enrollee to a health maintenance organization issued a certificate of authority to operate in 23
this State for covered services provided by the health care provider; 24
(ii) If Medicare is the primary insurer and a health maintenance 25
organization is the secondary insurer, any amount up to the Medicare approved or limiting 26
amount, as specified under the Social Security Act, that is not owed to the health care 27
provider by Medicare or the health maintenance organization after coordination of benefits 28
has been completed, for Medicare covered services provided to the subscriber or enrollee by 29
the health care provider; or 30
(iii) Any payment or charges for services that are not covered 31
services. 32
Article – Insurance 33
15–830. 34
HOUSE BILL 912 3
(a) (1) In this section the following words have the meanings indicated. 1
(2) “Carrier” means: 2
(i) an insurer that offers health insurance other than long–term 3
care insurance or disability insurance; 4
(ii) a nonprofit health service plan; 5
(iii) a health maintenance organization; 6
(iv) a dental plan organization; or 7
(v) except for a managed care organization as defined in Title 15, 8
Subtitle 1 of the Health – General Article, any other person that provides health benefit 9
plans subject to State regulation. 10
(3) (i) “Member” means an individual entitled to health care benefits 11
under a policy or plan issued or delivered in the State by a carrier. 12
(ii) “Member” includes a subscriber. 13
(4) “Nonphysician specialist” means a health care provider [who]: 14
(i) 1. WHO is not a physician; 15
[(ii)] 2. WHO is licensed or certified under the Health Occupations 16
Article; and 17
[(iii)] 3. WHO is certified or trained to treat or provide health care 18
services for a specified condition or disease in a manner that is within the scope of the 19
license or certification of the health care provider; OR 20
(II) THAT IS LICENSED AS A BEHAVIORAL HEALTH PROGRAM 21
UNDER § 7.5–401 OF THE HEALTH – GENERAL ARTICLE. 22
(5) (i) “Provider panel” means the providers that contract with a carrier 23
either directly or through a subcontracting entity to provide health care services to 24
enrollees of the carrier. 25
(ii) “Provider panel” does not include an arrangement in which any 26
provider may participate solely by contracting with the carrier to provide health care 27
services at a discounted fee–for–service rate. 28
4 HOUSE BILL 912
(6) “Specialist” means a physician who is certified or trained to practice in 1
a specified field of medicine and who is not designated as a primary care provider by the 2
carrier. 3
(b) (1) Each carrier that does not allow direct access to specialists shall 4
establish and implement a procedure by which a member may receive a standing referral 5
to a specialist in accordance with this subsection. 6
(2) The procedure shall provide for a standing referral to a specialist if: 7
(i) the primary care physician of the member determines, in 8
consultation with the specialist, that the member needs continuing care from the specialist; 9
(ii) the member has a condition or disease that: 10
1. is life threatening, degenerative, chronic, or disabling; and 11
2. requires specialized medical care; and 12
(iii) the specialist: 13
1. has expertise in treating the life –threatening, 14
degenerative, chronic, or disabling disease or condition; and 15
2. is part of the carrier’s provider panel. 16
(3) Except as provided in subsection (c) of this section, a standing referral 17
shall be made in accordance with a written treatment plan for a covered service developed 18
by: 19
(i) the primary care physician; 20
(ii) the specialist; and 21
(iii) the member. 22
(4) A treatment plan may: 23
(i) limit the number of visits to the specialist; 24
(ii) limit the period of time in which visits to the specialist are 25
authorized; and 26
(iii) require the specialist to communicate regularly with the primary 27
care physician regarding the treatment and health status of the member. 28
HOUSE BILL 912 5
(5) The procedure by which a member may receive a standing referral to a 1
specialist may not include a requirement that a member see a provider in addition to the 2
primary care physician before the standing referral is granted. 3
(c) (1) Notwithstanding any other provision of this section, a member who is 4
pregnant shall receive a standing referral to an obstetrician in accordance with this 5
subsection. 6
(2) After the member who is pregnant receives a standing referral to an 7
obstetrician, the obstetrician is responsible for the primary management of the member’s 8
pregnancy, including the issuance of referrals in accordance with the carrier’s policies and 9
procedures, through the postpartum period. 10
(3) A written treatment plan may not be required when a standing referral 11
is to an obstetrician under this subsection. 12
(d) (1) Each carrier shall establish and implement a procedure by which a 13
member may request a referral to a specialist or nonphysician specialist who is not part of 14
the carrier’s provider panel in accordance with this subsection. 15
(2) The procedure shall provide for a referral to a specialist or nonphysician 16
specialist who is not part of the carrier’s provider panel if: 17
(i) the member is diagnosed with a condition or disease that 18
requires specialized health care services or medical care; and 19
(ii) 1. the carrier does not have in its provider panel a specialist 20
or nonphysician specialist with the professional training and expertise to treat or provide 21
health care services for the condition or disease; or 22
2. the carrier cannot provide reasonable access to a specialist 23
or nonphysician specialist with the professional training and expertise to treat or provide 24
health care services for the condition or disease without unreasonable delay or travel. 25
(3) The procedure shall ensure that a request to obtain a referral to a 26
specialist or nonphysician specialist who is not part of the carrier’s provider panel is 27
addressed in a timely manner that is: 28
(i) appropriate for the member’s condition; and 29
(ii) in accordance with the timeliness requirements for 30
determinations made by private review agents under § 15–10B–06 of this title. 31
(4) The procedure may not be used by a carrier as a substitute for 32
establishing and maintaining a sufficient provider network in accordance with § 15–112 of 33
this title. 34
6 HOUSE BILL 912
(5) Each carrier shall: 1
(i) have a system in place that documents all requests to obtain a 2
referral to receive a covered service from a specialist or nonphysician specialist who is not 3
part of the carrier’s provider panel; [and] 4
(II) INFORM MEMBERS AND BENEFICIARIES , IN PLAIN 5
LANGUAGE, OF THE RIGHT PROCEDURE TO REQUEST A REFERRA L UNDER 6
PARAGRAPH (1) OF THIS SUBSECTION IN PRINT AND ELECTRO NIC PLAN DOCUMENTS 7
AND ANY PROVIDER DIRECTORY ; AND 8
[(ii)] (III) provide the information documented under item (i) of this 9
paragraph to the Commissioner on request. 10
(e) (1) For EXCEPT AS PROVIDED IN PARAGRAPH (2) OF THIS 11
SUBSECTION, FOR purposes of calculating any deductible, copayment amount, or 12
coinsurance payable by the member, a carrier shall treat services received in accordance 13
with subsection (d) of this section as if the service was provided by a provider on the 14
carrier’s provider panel. 15
(2) A CARRIER SHALL ENSURE THAT SERVICES RECEIVED IN 16
ACCORDANCE WITH SUBS ECTION (D) OF THIS SECTION FOR MENTAL HEALTH OR 17
SUBSTANCE USE DISORD ERS ARE PROVIDED AT NO GREATER COST TO T HE COVERED 18
INDIVIDUAL THAN IF T HE COVERED BENEFIT W ERE PROVIDED BY A PR OVIDER ON 19
THE CARRIER’S PROVIDER PANEL . 20
(2) ON REQUEST FOR AN IN –PERSON OR TELEHEALTH VISIT, IF THE 21
CARRIER’S PROVIDER PANEL HAS AN INSUFFICIENT NUMB ER OR TYPE OF 22
PARTICIPATING SPECIA LISTS OR NONPHYSICIA N SPECIALISTS WITH T HE EXPERTISE 23
TO PROVIDE THE COVER ED MENTAL HEALTH OR SUBSTANCE USE DISORDER 24
SERVICES REQUIRED UN DER § 15–802 OR § 15–840 OF THIS SUBTITLE TO A MEMBER 25
WITHIN THE APPOINTME NT WAITING TIME OR T RAVEL DISTANCE STAND ARDS 26
ESTABLISHED IN REGUL ATIONS, THE CARRIER SHALL CO VER THE SERVICES 27
PROVIDED BY A NONPA RTICIPATING PROVIDER AT NO GREATER COST T O THE 28
MEMBER THAN IF THE S ERVICES WERE PROVIDE D BY A PROVIDER ON T HE 29
CARRIER’S PROVIDER PANEL . 30
(3) EACH CARRIER SHALL US E THE REIMBURSEMENT RATE 31
ESTABLISHED UNDER PA RAGRAPH (4) OF THIS SUBSECTION T O: 32
(I) ENTER TIMELY SINGLE CASE AGREEMENTS ; AND 33
(II) PAY PROVIDERS . 34
HOUSE BILL 912 7
(4) (I) SUBJECT TO SUBPARAGRA PH (II) OF THIS PARAGRAPH , AND 1
NOT LATER THAN JANUARY 1, 2023, THE MARYLAND HEALTH COMMISSION SHALL 2
ESTABLISH A REIMBURS EMENT FORMULA TO DET ERMINE THE REIMBURS EMENT 3
RATE FOR NONPARTICIP ATING PROVIDERS THAT DELIVER SERVICES UND ER 4
PARAGRAPH (2) OF THIS SUBSECTION . 5
(II) THE MARYLAND HEALTH COMMISSION SHALL HOLD 6
PUBLIC MEETINGS WITH CARRIERS, MENTAL HEALTH AND SU BSTANCE USE 7
DISORDER PROVIDERS , CONSUMERS OF MENTAL HEALTH AND SU BSTANCE USE 8
DISORDER SERVICES , AND OTHER INTERESTED PARTIES TO DETERMINE THE 9
REIMBURSEMENT FORMUL A. 10
(f) A decision by a carrier not to provide access to or coverage of treatment or 11
health care services by a specialist or nonphysician specialist in accordance with this 12
section constitutes an adverse decision as defined under Subtitle 10A of this title if the 13
decision is based on a finding that the proposed service is not medically necessary, 14
appropriate, or efficient. 15
(g) (1) Each carrier shall file with the Commissioner a copy of each of the 16
procedures required under this section, including: 17
(i) steps the carrier requires of a member to request a referral; 18
(ii) the carrier’s timeline for decisions; and 19
(iii) the carrier’s grievance procedures for denials. 20
(2) Each carrier shall make a copy of each of the procedures filed under 21
paragraph (1) of this subsection available to its members: 22
(i) in the carrier’s online network directory required under § 23
15–112(n)(1) of this title; and 24
(ii) on request. 25
(H) THE CONSUMER EDUCATION AND ADVOCACY PROGRAM, ESTABLISHED 26
UNDER TITLE 2, SUBTITLE 3 OF THIS ARTICLE , IN COLLABORATION WIT H THE 27
HEALTH EDUCATION AND ADVOCACY UNIT OF THE OFFICE OF THE ATTORNEY 28
GENERAL, SHALL PROVIDE PUBLIC EDUCATION TO INFORM CONSUMERS OF TH EIR 29
RIGHT PROCEDURES TO REQUEST A REFERRA L TO A SPECIALIST OR NONPHYSICIAN 30
SPECIALIST AS PROVID ED FOR IN THIS SECTI ON. 31
(I) THIS SECTION MAY NOT BE CONSTRUED TO LIMI T THE PROVISIONS IN § 32
19–710(P) OF THE HEALTH – GENERAL ARTICLE. 33
8 HOUSE BILL 912
SECTION 2. AND BE IT FURTHER ENACTED, That, on or before December 31, 1
2022, the health occupations boards that license, certify, or otherwise regulate mental 2
health and substance use disorder providers under the Health Occupations Article shall 3
report to the Senate Finance Committee and the House Health and Government 4
Operations Committee, in accordance with § 2–1257 of the State Government Article, on 5
the progress the boards have made to develop a process for providing information on mental 6
health and substance use disorder providers to carriers for the purpose of the carriers 7
reaching out to the providers regarding participation in the carriers’ provider panels. 8
SECTION 2. 3. AND BE IT FURTHER ENACTED, That this Act shall apply to all 9
policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 10
after January 1, 2023. 11
SECTION 3. 4. AND BE IT FURTHER ENACTED, That this Act shall take effect 12
October 1, 2022. July 1, 2022. It shall remain effective for a period of 3 years and, at the 13
end of June 30, 2025, this Act, with no further action required by the General Assembly, 14
shall be abrogated and of no further force and effect. 15
Approved:
________________________________________________________________________________
Governor.
________________________________________________________________________________
Speaker of the House of Delegates.
________________________________________________________________________________
President of the Senate.