LAWRENCE J. HOGAN, JR., Governor Ch. 271
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Chapter 271
(House Bill 912)
AN ACT concerning
Health Insurance – Provider Panels – Coverage for Nonparticipation
FOR the purpose of requiring each carrier to inform members and beneficiaries of the right
procedure to request a referral to a specialist or nonphysician specialist who is not
part of the carrier’s provider panel; establishing a certain requirements requirement
on certain insurers, nonprofit health service plans, and health maintenance
organizations related to the coverage provision of certain mental health and
substance use disorder services provided to a member by a nonparticipating
provider; requiring the Consumer Education and Advocacy Program, in collaboration
with the Health Education and Advocacy Unit of the Office of the Attorney General,
to provide public education to inform consumers of certain rights procedures; and
generally relating to provider panels and coverage for nonparticipating providers.
BY repealing and reenacting, with amendments,
Article – Health – General
Section 19–710(p)
Annotated Code of Maryland
(2019 Replacement Volume and 2021 Supplement)
BY repealing and reenacting, with amendments,
Article – Insurance
Section 15–830
Annotated Code of Maryland
(2017 Replacement Volume and 2021 Supplement)
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND,
That the Laws of Maryland read as follows:
Article – Health – General
19–710.
(p) (1) Except as provided in paragraph (3) of this subsection, individual
enrollees and subscribers of health maintenance organizations issued certificates of
authority to operate in this State [shall] MAY not be liable to any health care provider for
any covered services provided to the enrollee or subscriber.
(2) (i) A health care provider or any representative of a health care
provider may not collect or attempt to collect from any subscriber or enrollee any money
owed to the health care provider by a health maintenance organization issued a certificate
of authority to operate in this State. Ch. 271 2022 LAWS OF MARYLAND
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(ii) A health care provider or any representative of a health care
provider may not maintain any action against any subscriber or enrollee to collect or
attempt to collect any money owed to the health care provider by a health maintenance
organization issued a certificate of authority to operate in this State.
(3) Notwithstanding any other provision of this subsection, a health care
provider or representative of a health care provider may collect or attempt to collect from a
subscriber or enrollee:
(i) Any copayment or coinsurance sums owed by the subscriber or
enrollee to a health maintenance organization issued a certificate of authority to operate in
this State for covered services provided by the health care provider;
(ii) If Medicare is the primary insurer and a health maintenance
organization is the secondary insurer, any amount up to the Medicare approved or limiting
amount, as specified under the Social Security Act, that is not owed to the health care
provider by Medicare or the health maintenance organization after coordination of benefits
has been completed, for Medicare covered services provided to the subscriber or enrollee by
the health care provider; or
(iii) Any payment or charges for services that are not covered
services.
Article – Insurance
15–830.
(a) (1) In this section the following words have the meanings indicated.
(2) “Carrier” means:
(i) an insurer that offers health insurance other than long–term
care insurance or disability insurance;
(ii) a nonprofit health service plan;
(iii) a health maintenance organization;
(iv) a dental plan organization; or
(v) except for a managed care organization as defined in Title 15,
Subtitle 1 of the Health – General Article, any other person that provides health benefit
plans subject to State regulation.
LAWRENCE J. HOGAN, JR., Governor Ch. 271
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(3) (i) “Member” means an individual entitled to health care benefits
under a policy or plan issued or delivered in the State by a carrier.
(ii) “Member” includes a subscriber.
(4) “Nonphysician specialist” means a health care provider [who]:
(i) 1. WHO is not a physician;
[(ii)] 2. WHO is licensed or certified under the Health Occupations
Article; and
[(iii)] 3. WHO is certified or trained to treat or provide health care
services for a specified condition or disease in a manner that is within the scope of the
license or certification of the health care provider; OR
(II) THAT IS LICENSED AS A BEHAVIORAL HEALTH PROGRAM
UNDER § 7.5–401 OF THE HEALTH – GENERAL ARTICLE.
(5) (i) “Provider panel” means the providers that contract with a carrier
either directly or through a subcontracting entity to provide health care services to
enrollees of the carrier.
(ii) “Provider panel” does not include an arrangement in which any
provider may participate solely by contracting with the carrier to provide health care
services at a discounted fee–for–service rate.
(6) “Specialist” means a physician who is certified or trained to practice in
a specified field of medicine and who is not designated as a primary care provider by the
carrier.
(b) (1) Each carrier that does not allow direct access to specialists shall
establish and implement a procedure by which a member may receive a standing referral
to a specialist in accordance with this subsection.
(2) The procedure shall provide for a standing referral to a specialist if:
(i) the primary care physician of the member determines, in
consultation with the specialist, that the member needs continuing care from the specialist;
(ii) the member has a condition or disease that:
1. is life threatening, degenerative, chronic, or disabling; and
2. requires specialized medical care; and
Ch. 271 2022 LAWS OF MARYLAND
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(iii) the specialist:
1. has expertise in treating the life –threatening,
degenerative, chronic, or disabling disease or condition; and
2. is part of the carrier’s provider panel.
(3) Except as provided in subsection (c) of this section, a standing referral
shall be made in accordance with a written treatment plan for a covered service developed
by:
(i) the primary care physician;
(ii) the specialist; and
(iii) the member.
(4) A treatment plan may:
(i) limit the number of visits to the specialist;
(ii) limit the period of time in which visits to the specialist are
authorized; and
(iii) require the specialist to communicate regularly with the primary
care physician regarding the treatment and health status of the member.
(5) The procedure by which a member may receive a standing referral to a
specialist may not include a requirement that a member see a provider in addition to the
primary care physician before the standing referral is granted.
(c) (1) Notwithstanding any other provision of this section, a member who is
pregnant shall receive a standing referral to an obstetrician in accordance with this
subsection.
(2) After the member who is pregnant receives a standing referral to an
obstetrician, the obstetrician is responsible for the primary management of the member’s
pregnancy, including the issuance of referrals in accordance with the carrier’s policies and
procedures, through the postpartum period.
(3) A written treatment plan may not be required when a standing referral
is to an obstetrician under this subsection.
(d) (1) Each carrier shall establish and implement a procedure by which a
member may request a referral to a specialist or nonphysician specialist who is not part of
the carrier’s provider panel in accordance with this subsection. LAWRENCE J. HOGAN, JR., Governor Ch. 271
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(2) The procedure shall provide for a referral to a specialist or nonphysician
specialist who is not part of the carrier’s provider panel if:
(i) the member is diagnosed with a condition or disease that
requires specialized health care services or medical care; and
(ii) 1. the carrier does not have in its provider panel a specialist
or nonphysician specialist with the professional training and expertise to treat or provide
health care services for the condition or disease; or
2. the carrier cannot provide reasonable access to a specialist
or nonphysician specialist with the professional training and expertise to treat or provide
health care services for the condition or disease without unreasonable delay or travel.
(3) The procedure shall ensure that a request to obtain a referral to a
specialist or nonphysician specialist who is not part of the carrier’s provider panel is
addressed in a timely manner that is:
(i) appropriate for the member’s condition; and
(ii) in accordance with the timeliness requirements for
determinations made by private review agents under § 15–10B–06 of this title.
(4) The procedure may not be used by a carrier as a substitute for
establishing and maintaining a sufficient provider network in accordance with § 15–112 of
this title.
(5) Each carrier shall:
(i) have a system in place that documents all requests to obtain a
referral to receive a covered service from a specialist or nonphysician specialist who is not
part of the carrier’s provider panel; [and]
(II) INFORM MEMBERS AND BENEFICIARIES, IN PLAIN
LANGUAGE, OF THE RIGHT PROCEDURE TO REQUEST A REFERRA L UNDER
PARAGRAPH (1) OF THIS SUBSECTION IN PRINT AND ELECTRO NIC PLAN DOCUMENTS
AND ANY PROVIDER DIRECTORY ; AND
[(ii)] (III) provide the information documented under item (i) of this
paragraph to the Commissioner on request.
(e) (1) For EXCEPT AS PROVIDED IN PARAGRAPH (2) OF THIS
SUBSECTION, FOR purposes of calculating any deductible, copayment amount, or
coinsurance payable by the member, a carrier shall treat services received in accordance Ch. 271 2022 LAWS OF MARYLAND
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with subsection (d) of this section as if the service was provided by a provider on the
carrier’s provider panel.
(2) A CARRIER SHALL ENSURE THAT SERVICES RECEIV ED IN
ACCORDANCE WITH SUBS ECTION (D) OF THIS SECTION FOR MENTAL HEALTH OR
SUBSTANCE USE DISORD ERS ARE PROVIDED AT NO GREATER COST TO T HE COVERED
INDIVIDUAL THAN IF T HE COVERED BENEFIT W ERE PROVIDED BY A PR OVIDER ON
THE CARRIER’S PROVIDER PANEL .
(2) ON REQUEST FOR AN IN –PERSON OR TELEHEALTH VISIT, IF THE
CARRIER’S PROVIDER PANEL HAS AN INSUFFI CIENT NUMBER OR TYPE OF
PARTICIPATING SPECIA LISTS OR NONPHYSICIA N SPECIALISTS WITH T HE EXPERTISE
TO PROVIDE THE COVER ED MENTAL HEALTH OR SUBSTANCE USE DISORD ER
SERVICES REQUIRED UN DER § 15–802 OR § 15–840 OF THIS SUBTITLE TO A MEMBER
WITHIN THE APPOINTMENT WAITING TIME OR TRAV EL DISTANCE STANDARD S
ESTABLISHED IN REGUL ATIONS, THE CARRIER SHALL CO VER THE SERVICES
PROVIDED BY A NONPAR TICIPATING PROVIDER AT NO GREATER COST T O THE
MEMBER THAN IF THE S ERVICES WERE PROVIDE D BY A PROVIDER ON T HE
CARRIER’S PROVIDER PANEL .
(3) EACH CARRIER SHALL US E THE REIMBURSEMENT RATE
ESTABLISHED UNDER PA RAGRAPH (4) OF THIS SUBSECTION T O:
(I) ENTER TIMELY SINGLE CASE AGREEMENTS ; AND
(II) PAY PROVIDERS .
(4) (I) SUBJECT TO SUBPARAGRA PH (II) OF THIS PARAGRAPH , AND
NOT LATER THAN JANUARY 1, 2023, THE MARYLAND HEALTH COMMISSION SHALL
ESTABLISH A REIMBURS EMENT FORMULA TO DET ERMINE THE REIMBURSE MENT
RATE FOR NONPARTICIP ATING PROVIDERS THAT DELIVER SERVICES UND ER
PARAGRAPH (2) OF THIS SUBSECTION .
(II) THE MARYLAND HEALTH COMMISSION SHALL HOLD
PUBLIC MEETINGS WITH CARRIERS, MENTAL HEALTH AND SU BSTANCE USE
DISORDER PROVIDERS , CONSUMERS OF MENTAL HEALTH AND SUBSTANCE USE
DISORDER SERVICES , AND OTHER INTERESTED PARTIES TO DETERMINE THE
REIMBURSEMENT FORMUL A.
(f) A decision by a carrier not to provide access to or coverage of treatment or
health care services by a specialist or nonphysician specialist in accordance with this
section constitutes an adverse decision as defined under Subtitle 10A of this title if the
decision is based on a finding that the proposed service is not medically necessary,
appropriate, or efficient. LAWRENCE J. HOGAN, JR., Governor Ch. 271
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(g) (1) Each carrier shall file with the Commissioner a copy of each of the
procedures required under this section, including:
(i) steps the carrier requires of a member to request a referral;
(ii) the carrier’s timeline for decisions; and
(iii) the carrier’s grievance procedures for denials.
(2) Each carrier shall make a copy of each of the procedures filed under
paragraph (1) of this subsection available to its members:
(i) in the carrier’s online network directory required under §
15–112(n)(1) of this title; and
(ii) on request.
(H) THE CONSUMER EDUCATION AND ADVOCACY PROGRAM, ESTABLISHED
UNDER TITLE 2, SUBTITLE 3 OF THIS ARTICLE , IN COLLABORATION WIT H THE
HEALTH EDUCATION AND ADVOCACY UNIT OF THE OFFICE OF THE ATTORNEY
GENERAL, SHALL PROVIDE PUBLIC EDUCATION TO INFORM CONSUMERS OF THEIR
RIGHT PROCEDURES TO REQUEST A REFERRA L TO A SPECIALIST OR NONPHYSICIAN
SPECIALIST AS PROVID ED FOR IN THIS SECTI ON.
(I) THIS SECTION MAY NOT BE CONSTRUED TO LIMI T THE PROVISIONS IN §
19–710(P) OF THE HEALTH – GENERAL ARTICLE.
SECTION 2. AND BE IT FURTHER ENACTED, That, on or before December 31,
2022, the health occupations boards that license, certify, or otherwise regulate mental
health and substance use disorder providers under the Health Occupations Article shall
report to the Senate Finance Committee and the House Health and Government
Operations Committee, in accordance with § 2–1257 of the State Government Article, on
the progress the boards have made to develop a process for providing information on mental
health and substance use disorder providers to carriers for the purpose of the carriers
reaching out to the providers regarding participation in the carriers’ provider panels.
SECTION 2. 3. AND BE IT FURTHER ENACTED, That this Act shall apply to all
policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or
after January 1, 2023.
SECTION 3. 4. AND BE IT FURTHER ENACTED, That this Act shall take effect
October 1, 2022. July 1, 2022. It shall remain effective for a period of 3 years and, at the
end of June 30, 2025, this Act, with no further action required by the General Assembly,
shall be abrogated and of no further force and effect.
Ch. 271 2022 LAWS OF MARYLAND
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Approved by the Governor, May 12, 2022.