EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*sb0308*
SENATE BILL 308
J5, J4, J1 3lr1125
CF HB 305
By: Senators Klausmeier and Hershey
Introduced and read first time: January 27, 2023
Assigned to: Finance
A BILL ENTITLED
AN ACT concerning 1
Health Insurance – Utilization Review – Revisions 2
FOR the purpose of altering and establishing requirements and prohibitions related to 3
health insurance utilization review, including provisions regarding benchmarks for 4
standardizing and automating the preauthorization process, the online 5
preauthorization system for payors, preauthorizations for prescription drugs, and 6
private review agents; altering timelines related to internal grievance procedures 7
and adverse decision procedures; increasing the penalties for violating certain 8
provisions of law regarding private review agents; requiring, rather than 9
authorizing, the Maryland Insurance Commissioner to establish certain reporting 10
requirements and requiring the Commissio ner to establish certain review 11
requirements related to private review agents; and generally relating to health 12
insurance and utilization review. 13
BY repealing and reenacting, with amendments, 14
Article – Health – General 15
Section 19–108.2 16
Annotated Code of Maryland 17
(2019 Replacement Volume and 2022 Supplement) 18
BY repealing and reenacting, without amendments, 19
Article – Insurance 20
Section 15–1A–14(a), 15–1001, and 15–10A–01(a) 21
Annotated Code of Maryland 22
(2017 Replacement Volume and 2022 Supplement) 23
BY repealing and reenacting, with amendments, 24
Article – Insurance 25
Section 15–1A–14(b), 15–854, 15–10A–01(k), 15–10A–02, 15–10A–06(a)(1)(vi), 26
15–10B–02, 15–10B–05 through 15–10B–07, 15–10B–11(8), 15–10B–12, and 27
15–10B–16 28 2 SENATE BILL 308
Annotated Code of Maryland 1
(2017 Replacement Volume and 2022 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
19–108.2. 6
(a) (1) In this section the following words have the meanings indicated. 7
(2) ‘‘Health care service” has the meaning stated in § 15–10A–01 of the 8
Insurance Article. 9
(3) “Payor” means: 10
(i) An insurer or nonprofit health service plan that provides 11
hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis 12
under health insurance policies or contracts that are issued or delivered in the State; 13
(ii) A health maintenance organization that provides hospital, 14
medical, or surgical benefits to individuals or groups under contracts that are issued or 15
delivered in the State; or 16
(iii) A pharmacy benefits manager that is registered with the 17
Maryland Insurance Commissioner. 18
(4) “Provider” has the meaning stated in § 19–7A–01 of this title. 19
(5) “Step therapy or fail–first protocol” has the meaning stated in § 15–142 20
of the Insurance Article. 21
(b) In addition to the duties stated elsewhere in this subtitle, the Commission 22
shall work with payors and providers to attain benchmarks for: 23
(1) Standardizing and automating the process required by payors for 24
preauthorizing health care services; and 25
(2) Overriding a payor’s step therapy or fail–first protocol. 26
(c) The benchmarks described in subsection (b) of this section shall include: 27
(1) [On or before October 1, 2012 (“Phase 1”), e stablishment] 28
ESTABLISHMENT of online access for providers to each payor’s: 29
(i) List of health care services that require preauthorization; and 30 SENATE BILL 308 3
(ii) Key criteria for making a determination on a preauthorization 1
request, INCLUDING CRITERIA I NCLUDED IN A CERTIFICATE APP LICATION BY A 2
PRIVATE REVIEW AGENT AS REQUIRED UNDER § 15–10B–05(A) OF THE INSURANCE 3
ARTICLE; 4
(2) [On or before March 1, 2013 (“Phase 2”), establishment ] 5
ESTABLISHMENT by each payor of an online process for: 6
(i) Accepting electronically a preauthorization request from a 7
provider; and 8
(ii) Assigning to a preauthorization request a unique electronic 9
identification number that a provider may use to track the request during the 10
preauthorization process, whether or not the request is tracked electronically, through a 11
call center, or by fax; 12
(3) [On or before July 1, 2013 (“Phase 3”), establishment ] 13
ESTABLISHMENT by each payor of an online preauthorization system to approve: 14
(i) In real time, electronic preauthorization requests for 15
pharmaceutical services: 16
1. For which no additional information is needed by the 17
payor to process the preauthorization request; and 18
2. That meet the payor’s criteria for approval, INCLUDING 19
THE CRITERIA INCLUDE D IN A CERTIFICATE A PPLICATION BY A PRIVAT E REVIEW 20
AGENT AS REQUIRED UN DER § 15–10B–05 OF THE INSURANCE ARTICLE; 21
(ii) Within 1 [business] CALENDAR day after receiving all pertinent 22
information on requests not approved in real time, electronic preauthorization requests for 23
pharmaceutical services that: 24
1. Are not urgent; and 25
2. Do not meet the standards for real–time approval under 26
item (i) of this item; and 27
(iii) Within 2 [business] CALENDAR days after receiving all 28
pertinent information, electronic preauthorization requests for health care services, except 29
pharmaceutical services, that are not urgent; 30
(4) [On or before July 1, 2015, establishment] ESTABLISHMENT , by each 31
payor that requires a step therapy or fail–first protocol, of a process for a provider to 32
override the step therapy or fail–first protocol of the payor; and 33 4 SENATE BILL 308
(5) [On or before July 1, 2015, utilization] UTILIZATION by providers of: 1
(i) The online preauthorization system established by payors; or 2
(ii) If a national transaction standard has been established and 3
adopted by the health care industry, as determined by the Commission, the provider’s 4
practice management, electronic health record, or e–prescribing system. 5
(d) The benchmarks described in subsections (b) and (c) of this section do not 6
apply to preauthorizations of health care services requested by providers employed by a 7
group model health maintenance organization as defined in § 19–713.6 of this title. 8
(e) The online preauthorization system described in subsection (c)(3) of this 9
section shall: 10
(1) Provide real–time notice to providers about preauthorization requests 11
approved in real time; [and] 12
(2) Provide notice to providers, within the time frames specified in 13
subsection (c)(3)(ii) and (iii) of this section and in a manner that is able to be tracked by 14
providers, about preauthorization requests not approved in real time; AND 15
(3) COMPLY WITH ANY ADDIT IONAL UTILIZATION RE VIEW CRITERIA 16
REQUIRED UNDER TITLE 15, SUBTITLE 10 OF THE INSURANCE ARTICLE. 17
(f) (1) The Commission shall establish by regulation a process through which 18
a payor or provider may be waived from attaining the benchmarks described in subsections 19
(b) and (c) of this section for extenuating circumstances. 20
(2) For a provider, the extenuating circumstances may include: 21
(i) The lack of broadband Internet access; 22
(ii) Low patient volume; or 23
(iii) Not making medical referrals or prescribing pharmaceuticals. 24
(3) For a payor, the extenuating circumstances may include: 25
(i) Low premium volume; or 26
(ii) For a group model health maintenance organization, as defined 27
in § 19–713.6 of this title, preauthorizations of health care services requested by providers 28
not employed by the group model health maintenance organization. 29
SENATE BILL 308 5
(g) [(1) On or before October 1, 2012, the Commission shall reconvene the 1
multistakeholder workgroup whose collaboration resulted in the 2011 report 2
“Recommendations for Implementing Electronic Prior Authorizations”. 3
(2) The workgroup shall: 4
(i) Review the progress to date in attaining the benchmarks 5
described in subsections (b) and (c) of this section; and 6
(ii) Make recommendations to the Commission for adjustments to 7
the benchmark dates. 8
(h)] If necessary to attain the benchmarks, the Commission may adopt regulations 9
to: 10
(1) [Adjust the Phase 2 or Phase 3 benchmark dates; 11
(2)] Require payors and providers to comply with the benchmarks; and 12
[(3)] (2) Establish penalties for noncompliance. 13
Article – Insurance 14
15–1A–14. 15
(a) (1) In this section the following words have the meanings indicated. 16
(2) “Emergency medical condition” means a medical condition that 17
manifests itself by acute symptoms of such severity, including severe pain, that the absence 18
of immediate medical attention could reasonably be expected by a prudent layperson, who 19
possesses an average knowledge of health and medicine, to result in a condition described 20
in § 1867(e)(1) of the Social Security Act. 21
(3) “Emergency services” means, with respect to an emergency medical 22
condition: 23
(i) a medical screening examination that is within the capability of 24
the emergency department of a hospital or freestanding medical facility, including ancillary 25
services routinely available to the emergency department to evaluate an emergency 26
medical condition; or 27
(ii) any other examination or treatment within the capabilities of the 28
staff and facilities available at the hospital or freestanding medical facility that is necessary 29
to stabilize the patient. 30
(b) If a carrier provides or covers any benefits for emergency services in an 31
emergency department of a hospital or freestanding medical facility, the carrier: 32 6 SENATE BILL 308
(1) may not require an insured individual to obtain prior authorization for 1
the emergency services, INCLUDING HEALTH CAR E SERVICES PROVIDED 2
POSTEVALUATION OR PO STSTABILIZATION THAT ARE NECESSARY TO DIS CHARGE 3
THE PATIENT; and 4
(2) shall provide coverage for the emergency services regardless of whether 5
the health care provider providing the emergency services has a contractual relationship 6
with the carrier to furnish emergency services. 7
15–854. 8
(a) (1) This section applies to: 9
(i) insurers and nonprofit health service plans that provide coverage 10
for prescription drugs through a pharmacy benefit under individual, group, or blanket 11
health insurance policies or contracts that are issued or delivered in the State; and 12
(ii) health maintenance organizations that provide coverage for 13
prescription drugs through a pharmacy benefit under individual or group contracts that 14
are issued or delivered in the State. 15
(2) An insurer, a nonprofit health service plan, or a health maintenance 16
organization that provides coverage for prescription drugs through a pharmacy benefits 17
manager or that contracts with a private review agent under Subtitle 10B of this article is 18
subject to the requirements of this section. 19
(3) This section does not apply to a managed care organization as defined 20
in § 15–101 of the Health – General Article. 21
(b) [(1) (i) If an entity subject to this section requires a prior authorization 22
for a prescription drug, the prior authorization request shall allow a health care provider 23
to indicate whether a prescription drug is to be used to treat a chronic condition. 24
(ii) If a health care provider indicates that the prescription drug is 25
to treat a chronic condition, an entity subject to this section may not request a 26
reauthorization for a repeat prescription for the prescription drug for 1 year or for the 27
standard course of treatment for the chronic condition being treated, whichever is less. 28
(2)] For a prior authorization FOR A PRESCRIPTION D RUG that is filed 29
electronically, the entity shall maintain a database that will prepopulate prior 30
authorization requests with an insured’s available insurance and demographic 31
information. 32
(c) [If] IN ADDITION TO THE RE QUIREMENTS IN SUBTITLES 10A AND 10B 33
OF THIS TITLE, IF an entity subject to this section [denies] ISSUES AN ADVERSE 34 SENATE BILL 308 7
DECISION DENYING coverage for a prescription drug, the entity shall provide a detailed 1
written explanation for the denial of coverage, including whether the denial was based on 2
a requirement for prior authorization. 3
(d) (1) On receipt of information documenting a prior authorization from the 4
insured or from the insured’s health care provider, an entity subject to this section shall 5
honor a prior authorization granted to an insured from a previous entity for at least the 6
[initial 30] LESSER OF 90 days [of an insured’s prescription drug benefit coverage under 7
the health benefit plan of the new entity] OR THE LENGTH OF THE COURSE OF 8
TREATMENT . 9
(2) During the time period described in paragraph (1) of this subsection, an 10
entity may perform its own review to grant a prior authorization for the prescription drug. 11
(e) (1) An entity subject to this section shall honor a prior authorization issued 12
by the entity for a prescription drug: 13
(i) if the insured changes health benefit plans that are both covered 14
by the same entity and the prescription drug is a covered benefit under the current health 15
benefit plan; or 16
(ii) except as provided in paragraph (2) of this subsection, when the 17
dosage for the approved prescription drug changes and the change is consistent with federal 18
Food and Drug Administration labeled dosages. 19
(2) An entity may not be required to honor a prior authorization for a 20
change in dosage for an opioid under this subsection. 21
(F) AN ENTITY SUBJECT TO THIS SECTION MAY NOT REQUIRE A PRIOR 22
AUTHORIZATION FOR : 23
(1) A CHANGE IN DOSAGE O F A PRESCRIPTION DRU G BY A 24
PRESCRIBER IF THE EN TITY HAS ALREADY PREAUTHOR IZED THE USE OF THE 25
PRESCRIPTION DRUG FO R THE INSURED AND TH E DOSAGE CHANGE IS C ONSISTENT 26
WITH FEDERAL FOOD AND DRUG ADMINISTRATION LABELE D DOSAGES; 27
(2) A PRESCRIPTION DRUG THAT IS A GENERIC ; OR 28
(3) A PRESCRIPTION DRUG IF: 29
(I) THE INSURED RECEIVED AN INITIAL PRIOR AUT HORIZATION 30
FOR THE PRESCRIPTION DRUG; AND 31
8 SENATE BILL 308
(II) BASED ON THE PROFESS IONAL JUDGMENT OF TH E 1
PRESCRIBER, THE PRESCRIPTION DRU G IS EFFECTIVELY TRE ATING THE INSURED ’S 2
MEDICAL CONDITION . 3
(G) AN ENTITY SUBJECT TO THIS SECTION MAY NOT REQUIRE MORE THAN 4
ONE PRIOR AUTHORIZAT ION FOR A PRESCRIPTI ON DRUG WITH DIFFERE NT 5
FORMULATIONS THAT IS PRESCRIBED THROUGH T WO OR MORE PRESCRIPT IONS AT 6
THE SAME TIME AS PAR T OF AN INSURED’S TREATMENT PLAN . 7
[(f)] (H) If an entity under this section implements a new prior authorization 8
requirement for a prescription drug, the entity shall provide notice of the new requirement 9
at least 30 days before the implementation of a new prior authorization requirement: 10
(1) in writing to any insured who is prescribed the prescription drug; and 11
(2) either in writing or electronically to all contracted health care 12
providers. 13
15–1001. 14
(a) This section applies to entities that propose to issue or deliver individual, 15
group, or blanket health insurance policies or contracts in the State or to administer health 16
benefit programs that provide for the coverage of health care services and the utilization 17
review of those services, including: 18
(1) an authorized insurer that provides health insurance in the State; 19
(2) a nonprofit health service plan; 20
(3) a health maintenance organization; 21
(4) a dental plan organization; or 22
(5) except for a managed care organization as defined in Title 15, Subtitle 23
1 of the Health – General Article, any other person that provides health benefit plans 24
subject to regulation by the State. 25
(b) (1) Subject to paragraph (2) of this subsection, each entity subject to this 26
section shall: 27
(i) 1. have a certificate issued under Subtitle 10B of this title; or 28
2. contract with a private review agent that has a certificate 29
issued under Subtitle 10B of this title; and 30
SENATE BILL 308 9
(ii) when conducting utilization review for mental health and 1
substance use benefits, ensure that the criteria and standards used are in compliance with 2
the federal Mental Health Parity and Addiction Equity Act. 3
(2) For hospital services, each entity subject to this section may contract 4
with or delegate utilization review to a hospital utilization review program approved under 5
§ 19–319(d) of the Health – General Article. 6
(c) Notwithstanding any other provision of this article, if the medical necessity of 7
providing a covered benefit is disputed, an entity subject to this section that does not meet 8
the requirements of subsection (b) of this section shall pay any person entitled to 9
reimbursement under the policy or contract in accordance with the determination of 10
medical necessity by: 11
(1) the treating provider; or 12
(2) when hospital services are provided, the hospital utilization review 13
program approved under § 19–319(d) of the Health – General Article. 14
(d) An entity subject to this section may not: 15
(1) act as a private review agent without holding a certificate issued under 16
Subtitle 10B of this title; or 17
(2) use a private review agent that does not hold a certificate issued under 18
Subtitle 10B of this title. 19
(e) An entity that violates any provision of this section is subject to the penalties 20
provided under § 15–10B–12 of this title. 21
15–10A–01. 22
(a) In this subtitle the following words have the meanings indicated. 23
(k) “Health care service” means a health or medical care procedure or service 24
rendered by a health care provider that: 25
(1) provides testing, diagnosis, or treatment of a human disease or 26
dysfunction; [or] 27
(2) dispenses drugs, medical devices, medical appliances, or medical goods 28
for the treatment of a human disease or dysfunction; OR 29
(3) PROVIDES ANY OTHER C ARE, SERVICE, OR TREATMENT OF 30
DISEASE OR INJURY , THE CORRECTION OF DE FECTS, OR THE MAINTENANCE O F 31
PHYSICAL OR MENTAL WELL –BEING OF HUMAN BEING S. 32 10 SENATE BILL 308
15–10A–02. 1
(a) Each carrier shall establish an internal grievance process for its members. 2
(b) (1) An internal grievance process shall meet the same requirements 3
established under Subtitle 10B of this title. 4
(2) In addition to the requirements of Subtitle 10B of this title, an internal 5
grievance process established by a carrier under this section shall: 6
(i) include an expedited procedure for use in an emergency case for 7
purposes of rendering a grievance decision within 24 hours of the date a grievance is filed 8
with the carrier; 9
(ii) provide that a carrier render a final decision in writing on a 10
grievance within [30 working] 10 CALENDAR days after the date on which the grievance 11
is filed unless: 12
1. the grievance involves an emergency case under item (i) of 13
this paragraph; 14
2. the member, the member’s representative, or a health care 15
provider filing a grievance on behalf of a member agrees in writing to an extension for a 16
period of no longer than 30 working days; or 17
3. the grievance involves a retrospective denial under item 18
(iv) of this paragraph; 19
(iii) allow a grievance to be filed on behalf of a member by a health 20
care provider or the member’s representative; 21
(iv) provide that a carrier render a final decision in writing on a 22
grievance within [45 working] 30 CALENDAR days after the date on which the grievance 23
is filed when the grievance involves a retrospective denial; and 24
(v) for a retrospective denial, allow a member, the membe r’s 25
representative, or a health care provider on behalf of a member to file a grievance for at 26
least 180 days after the member receives an adverse decision. 27
(3) For purposes of using the expedited procedure for an emergency case 28
that a carrier is required to include under paragraph (2)(i) of this subsection, the 29
Commissioner shall define by regulation the standards required for a grievance to be 30
considered an emergency case. 31
SENATE BILL 308 11
(c) Except as provided in subsection (d) of this section, the carrier’s internal 1
grievance process shall be exhausted prior to filing a complaint with the Commissioner 2
under this subtitle. 3
(d) (1) (i) A member, the member’s representative, or a health care 4
provider filing a complaint on behalf of a member may file a complaint with the 5
Commissioner without first filing a grievance with a carrier and receiving a final decision 6
on the grievance if: 7
1. the carrier waives the requirement that the carrier’s 8
internal grievance process be exhausted before filing a complaint with the Commissioner; 9
2. the carrier has failed to comply with any of the 10
requirements of the internal grievance process as described in this section; or 11
3. the member, the member’s representative, or the health 12
care provider provides sufficient information and supporting documentation in the 13
complaint that demonstrates a compelling reason to do so. 14
(ii) The Commissioner shall define by regulation the standards that 15
the Commissioner shall use to decide what demonstrates a compelling reason under 16
subparagraph (i) of this paragraph. 17
(2) Subject to subsections (b)(2)(ii) and (h) of this section, a member, a 18
member’s representative, or a health care provider may file a complaint with the 19
Commissioner if the member, the member’s representative, or the health care provider does 20
not receive a grievance decision from the carrier on or before the [30th working] 10TH 21
CALENDAR day on which the grievance is filed. 22
(3) Whenever the Commissioner receives a complaint under paragraph (1) 23
or (2) of this subsection, the Commissioner shall notify the carrier that is the subject of the 24
complaint within 5 working days after the date the complaint is filed with the 25
Commissioner. 26
(e) Each carrier shall: 27
(1) file for review with the Commissioner and submit to the Health 28
Advocacy Unit a copy of its internal grievance process established under this subtitle; and 29
(2) file any revision to the internal grievance process with the 30
Commissioner and the Health Advocacy Unit at least 30 days before its intended use. 31
(f) For nonemergency cases, when a carrier renders an adverse decision, the 32
carrier shall: 33
(1) AFTER COMPLYING WITH § 15–10B–07(A) OF THIS TITLE, document 34
the adverse decision in writing [after the carrier has provided] AND PROVIDE oral 35 12 SENATE BILL 308
communication of the decision to the member, the member’s representative, or the health 1
care provider acting on behalf of the member; and 2
(2) send, within [5 working] 2 CALENDAR days after the adverse decision 3
has been made, a written notice to the member, the member’s representative, and a health 4
care provider acting on behalf of the member that: 5
(i) states in detail in clear, understandable language the specific 6
factual bases for the carrier’s decision; 7
(ii) references the specific criteria and standards, including 8
interpretive guidelines, on which the decision was based, and may not solely use 9
generalized terms such as “experimental procedure not covered”, “cosmetic procedure not 10
covered”, “service included under another procedure”, or “not medically necessary”; 11
(iii) states the name, business address, and business telephone 12
number of: 13
1. the medical director or associate medical director, as 14
appropriate, who made the decision if the carrier is a health maintenance organization; or 15
2. the designated employee or representative of the carrier 16
who has responsibility for the carrier’s internal grievance process if the carrier is not a 17
health maintenance organization; 18
(iv) gives written details of the carrier’s internal grievance process 19
and procedures under this subtitle; and 20
(v) includes the following information: 21
1. that the member, the member’s representative, or a health 22
care provider on behalf of the member has a right to file a complaint with the Commissioner 23
within 4 months after receipt of a carrier’s grievance decision; 24
2. that a complaint may be filed without first filing a 25
grievance if the member, the member’s representative, or a health care provider filing a 26
grievance on behalf of the member can demonstrate a compelling reason to do so as 27
determined by the Commissioner; 28
3. the Commissioner’s address, telephone number, and 29
facsimile number; 30
4. a statement that the Health Advocacy Unit is available to 31
assist the member or the member’s representative in both mediating and filing a grievance 32
under the carrier’s internal grievance process; and 33
SENATE BILL 308 13
5. the address, telephone number, facsimile number, and 1
electronic mail address of the Health Advocacy Unit. 2
(g) If within [5 working] 3 CALENDAR days after a member, the member’s 3
representative, or a health care provider, who has filed a grievance on behalf of a member, 4
files a grievance with the carrier, and if the carrier does not have sufficient information to 5
complete its internal grievance process, the carrier shall: 6
(1) notify the member, the member’s representative, or the health care 7
provider that it cannot proceed with reviewing the grievance unless additional information 8
is provided AND SPECIFY: 9
1. THE ADDITIONAL INFOR MATION THAT MUST BE 10
PROVIDED TO COMPLETE THE INTERNAL GRIEVANCE PRO CESS; AND 11
2. THE CRITERIA AND STA NDARDS TO SUPPORT TH E 12
NEED FOR THE ADDITIO NAL INFORMATION ; and 13
(2) assist the member, the member’s representative, or the health care 14
provider in gathering the necessary information without further delay. 15
(h) A carrier may extend the [30–day] 10–DAY or [45–day] 30–DAY period 16
required for making a final grievance decision under subsection (b)(2)(ii) of this section with 17
the written consent of the member, the member’s representative, or the health care 18
provider who filed the grievance on behalf of the member. 19
(i) (1) For nonemergency cases, when a carrier renders a grievance decision, 20
the carrier shall: 21
(i) document the grievance decision in writing after the carrier has 22
provided oral communication of the decision to the member, the member’s representative, 23
or the health care provider acting on behalf of the member; and 24
(ii) send, within [5 working] 3 CALENDAR days after the grievance 25
decision has been made, a written notice to the member, the member’s representative, and 26
a health care provider acting on behalf of the member that: 27
1. states in detail in clear, understandable language the 28
specific factual bases for the carrier’s decision; 29
2. references the specific criteria and standards, including 30
interpretive guidelines, on which the grievance decision was based; 31
3. states the name, business address, and business telephone 32
number of: 33
14 SENATE BILL 308
A. the medical director or associate medical director, as 1
appropriate, who made the grievance decision if the carrier is a health maintenance 2
organization; or 3
B. the designated employee or representative of the carrier 4
who has responsibility for the carrier’s internal grievance process if the carrier is not a 5
health maintenance organization; and 6
4. includes the following information: 7
A. that the member or the member’s representative has a 8
right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s 9
grievance decision; 10
B. the Commissioner’s address, telephone number, and 11
facsimile number; 12
C. a statement that the Health Advocacy Unit is available to 13
assist the member or the member’s representative in filing a complaint with the 14
Commissioner; and 15
D. the address, telephone number, facsimile number, and 16
electronic mail address of the Health Advocacy Unit. 17
(2) A carrier may not use solely in a notice sent under paragraph (1) of this 18
subsection generalized terms such as “experimental procedure not covered”, “cosmetic 19
procedure not covered”, “service included under another procedure”, or “not medically 20
necessary” to satisfy the requirements of this subsection. 21
(j) (1) For an emergency case under subsection (b)(2)(i) of this section, AFTER 22
THE CARRIER HAS COMP LIED WITH § 15–10B–07(A) OF THIS TITLE AND within 1 23
CALENDAR day after a decision has been orally communicated to the member, the 24
member’s representative, or the health care provider, the carrier shall send notice in 25
writing of any adverse decision or grievance decision to: 26
(i) the member and the member’s representative, if any; and 27
(ii) if the grievance was filed on behalf of the member under 28
subsection (b)(2)(iii) of this section, the health care provider. 29
(2) A notice required to be sent under paragraph (1) of this subsection shall 30
include the following: 31
(i) for an adverse decision, the information required under 32
subsection (f) of this section; and 33
SENATE BILL 308 15
(ii) for a grievance decision, the information required under 1
subsection (i) of this section. 2
(k) (1) Each carrier shall include the information required by subsection 3
(f)(2)(iii), (iv), and (v) of this section in the policy, plan, certificate, enrollment materials, or 4
other evidence of coverage that the carrier provides to a member at the time of the member’s 5
initial coverage or renewal of coverage. 6
(2) Each carrier shall include as part of the information required by 7
paragraph (1) of this subsection a statement indicating that, when filing a complaint with 8
the Commissioner, the member or the member’s representative will be required to 9
authorize the release of any medical records of the member that may be required to be 10
reviewed for the purpose of reaching a decision on the complaint. 11
(l) (1) Nothing in this subtitle prohibits a carrier from delegating its internal 12
grievance process to a private review agent that has a certificate issued under Subtitle 10B 13
of this title and is acting on behalf of the carrier. 14
(2) If a carrier delegates its internal grievance process to a private review 15
agent, the carrier shall be: 16
(i) bound by the grievance decision made by the private review 17
agent acting on behalf of the carrier; and 18
(ii) responsible for a violation of any provision of this subtitle 19
regardless of the delegation made by the carrier under paragraph (1) of this subsection. 20
15–10A–06. 21
(a) On a quarterly basis, each carrier shall submit to the Commissioner, on the 22
form the Commissioner requires, a report that describes: 23
(1) the activities of the carrier under this subtitle, including: 24
(vi) 1. the number of adverse decisions issued by the carrier 25
under § 15–10A–02(f) of this subtitle [and]; 26
2. the type of service AND THE HEALTH CARE SPECIALTY 27
at issue in the adverse decisions; AND 28
3. THE UTILIZATION MANA GEMENT TECHNIQUE USE D BY 29
THE CARRIER IN ISSUI NG THE ADVERSE DECIS IONS; and 30
15–10B–02. 31
The purpose of this subtitle is to: 32 16 SENATE BILL 308
(1) promote the delivery of quality health care in a cost effective manner 1
THAT ENSURES TIMELY ACCESS TO HEALTH CAR E SERVICES; 2
(2) foster greater coordination, COMMUNICATION , AND TRANSPARENCY 3
between payors and providers conducting utilization review activities; 4
(3) protect patients, business, and providers by ensuring that private 5
review agents are qualified to perform utilization review activities and to make informed 6
decisions on the appropriateness of medical care; and 7
(4) ensure that private review agents maintain the confidentiality of 8
medical records in accordance with applicable State and federal laws. 9
15–10B–05. 10
(a) In conjunction with the application, the private review agent shall submit 11
information that the Commissioner requires including: 12
(1) a utilization review plan that includes: 13
(i) the specific criteria and standards to be used in conducting 14
utilization review of proposed or delivered health care services IN ACCORDANCE WITH 15
ITEM (11) OF THIS SUBSECTION ; 16
(ii) those circumstances, if any, under which utilization review may 17
be delegated to a hospital utilization review program; and 18
(iii) if applicable, any provisions by which patients, physicians, or 19
hospitals may seek reconsideration; 20
(2) the type and qualifications of the personnel either employed or under 21
contract to perform the utilization review; 22
(3) a copy of the private review agent’s internal grievance process if a 23
carrier delegates its internal grievance process to the private review agent in accordance 24
with § 15–10A–02(l) of this title; 25
(4) the procedures and policies to ensure: 26
(I) that a representative of the private review agent is reasonably 27
accessible to patients and health care providers 7 days a week, 24 hours a day in this State; 28
AND 29
(II) COMPLIANCE WITH § 15–10B–07 OF THIS SUBTITLE ; 30
SENATE BILL 308 17
(5) if applicable, the procedures and policies to ensure that a representative 1
of the private review agent is accessible to health care providers to make all determinations 2
on whether to authorize or certify an emergency inpatient admission, or an admission for 3
residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, 4
emotional, or substance abuse disorder within 2 hours after receipt of the information 5
necessary to make the determination; 6
(6) the policies and procedures to ensure that all applicable State and 7
federal laws to protect the confidentiality of individual medical records are followed; 8
(7) a copy of the materials designed to inform applicable patients and 9
providers of the requirements of the utilization review plan; 10
(8) a list of the third party payors for which the private review agent is 11
performing utilization review in this State; 12
(9) the policies and procedures to ensure that the private review agent has 13
a formal program for the orientation and training of the personnel either employed or under 14
contract to perform the utilization review; 15
(10) a list of the persons AND THEIR QUALIFICAT IONS, INCLUDING ANY 16
CERTIFICATIONS AND C LINICAL SPECIALTIES , involved in establishing the specific 17
criteria and standards to be used in conducting utilization review; and 18
(11) certification by the private review agent that the criteria and standards 19
to be used in conducting utilization review [are]: 20
[(i) objective; 21
(ii) clinically valid; 22
(iii) compatible with established principles of health care; and 23
(iv) flexible enough to allow deviations from norms when justified on 24
a case by case basis] 25
(I) ARE EVIDENCE –BASED, PEER–REVIEWED, AND DEVELOPED 26
BY: 27
1. AN ORGANIZATION THAT WORKS DIRECTLY WITH 28
HEALTH CARE PROVIDERS IN THE SAME SPECIALT Y FOR THE DESIGNATED CRITERIA 29
WHO ARE EMPLOYED OR ENGAGED WITHIN THE O RGANIZATION OR OUTSI DE THE 30
ORGANIZATION TO DEVE LOP THE CLINICAL CRI TERIA, PROVIDED THAT THE 31
ORGANIZATION DOES NO T RECEIVE DIRECT PAY MENTS BASED O N THE OUTCOME OR 32
PRIOR AUTHORIZATION DECISIONS; OR 33
18 SENATE BILL 308
2. A PROFESSIONAL MEDIC AL SPECIALTY SOCIETY ; AND 1
(II) SHALL: 2
1. TAKE INTO ACCOUNT TH E NEEDS OF ATYPICAL 3
PATIENT POPULATIONS AND DIAGNOSES ; 4
2. ENSURE QUALITY OF CA RE AND ACCESS TO NEE DED 5
HEALTH CARE SERVICES ; 6
3. BE SUFFICIENTLY FLEX IBLE TO ALLOW DEVIAT IONS 7
FROM NORMS WHEN JUST IFIED ON A CASE–BY–CASE BASIS; AND 8
4. BE EVALUATED AT LEAS T ANNUALLY AND UPDAT ED 9
AS NECESSARY . 10
(b) (1) [On the written request of any person or health care facility, the] THE 11
private review agent shall [provide 1 copy of] POST the specific criteria and standards to 12
be used in conducting utilization review of proposed or delivered services and any 13
subsequent revisions, modifications, or additions to the specific criteria and standards to 14
be used in conducting utilization review of proposed or delivered services [to the person or 15
health care facility making the request] IN ACCORDANCE WITH § 19–108.2(C)(1) OF THE 16
HEALTH – GENERAL ARTICLE. 17
(2) THE INFORMATION POSTED IN ACCORDANCE WITH PARAGRAPH 18
(1) OF THIS SUBSECTION S HALL INCLUDE THE INF ORMATION REQUIRED UN DER 19
SUBSECTION (A)(10) OF THIS SECTION. 20
(c) [The private review agent may charge a reasonable fee for a copy of the specific 21
criteria and standards or any subsequent revisions, modifications, or additions to the 22
specific criteria to any person or health care facility requesting a copy under subsection (b) 23
of this section. 24
(d)] A private review agent shall advise the Commissioner, in writing, of a change 25
in: 26
(1) ownership, medical director, or chief executive officer within 30 days of 27
the date of the change; 28
(2) the name, address, or telephone number of the private review agent 29
within 30 days of the date of the change; or 30
(3) the private review agent’s scope of responsibility under a contract. 31
15–10B–06. 32 SENATE BILL 308 19
(a) (1) [A] EXCEPT AS PROVIDED IN § 19–108.2 OF THE HEALTH – 1
GENERAL ARTICLE, A private review agent shall: 2
(i) make all initial determinations on whether to authorize or certify 3
a nonemergency course of treatment for a patient within 2 [working] CALENDAR days after 4
receipt of the information necessary to make the determination; 5
(ii) make all determinations on whether to authorize or certify an 6
extended stay in a health care facility or additional health care services within 1 [working] 7
CALENDAR day after receipt of the information necessary to make the determination; and 8
(iii) promptly notify the health care provider of the determination. 9
(2) If within [3] 2 calendar days after receipt of the initial request for 10
health care services the private review agent does not have sufficient information to make 11
a determination, the private review agent shall [inform] SPECIFY TO the health care 12
provider [that]: 13
(I) THE additional information THAT must be provided TO MAKE 14
THE DETERMINATION ; AND 15
(II) THE CRITERIA AND STA NDARDS TO SUPPORT TH E NEED FOR 16
THE ADDITIONAL INFOR MATION. 17
(3) If a private review agent requires prior authorization for an emergency 18
inpatient admission, or an admission for residential crisis services as defined in § 15–840 19
of this title, for the treatment of a mental, emotional, or substance abuse disorder, the 20
private review agent shall: 21
(i) make all determinations on whether to authorize or certify an 22
inpatient admission, or an admission for residential crisis services as defined in § 15–840 23
of this title, within 2 hours after receipt of the information necessary to make the 24
determination; and 25
(ii) promptly notify the health care provider of the determination. 26
[(b) If an initial determination is made by a private review agent not to authorize 27
or certify a health care service and the health care provider believes the determination 28
warrants an immediate reconsideration, a private review agent may provide the health 29
care provider the opportunity to speak with the physician that rendered the determination, 30
by telephone on an expedited basis, within a period of time not to exceed 24 hours of the 31
health care provider seeking the reconsideration.] 32
20 SENATE BILL 308
(B) BEFORE ISSUING AN ADVERSE DECISION, A PRIVATE REVIEW AGE NT 1
SHALL GIVE THE PATIE NT’S TREATING PHYSICIAN , DENTIST, OR OTHER HEALTH 2
CARE PRACTITIONER TH E OPPORTUNITY TO SPE AK ABOUT THE MEDICAL NECESSITY 3
OF THE TREATMENT REQ UEST WITH THE PHYSIC IAN, DENTIST, OR PANE L 4
RESPONSIBLE FOR THE ADVERSE DECISION . 5
(c) For emergency inpatient admissions, a private review agent may not render 6
an adverse decision solely because the hospital did not notify the private review agent of 7
the emergency admission within 24 hours or other prescribed period of time after that 8
admission if the patient’s medical condition prevented the hospital from determining: 9
(1) the patient’s insurance status; and 10
(2) if applicable, the private review agent’s emergency admission 11
notification requirements. 12
(d) (1) Subject to paragraph (2) of this subsection, a private review agent may 13
not render an adverse decision as to an admission of a patient during the first 24 hours 14
after admission when: 15
(i) the admission is based on a determination that the patient is in 16
imminent danger to self or others; 17
(ii) the determination has been made by the patient’s physician or 18
psychologist in conjunction with a member of the medical staff of the facility who has 19
privileges to make the admission; and 20
(iii) the hospital immediately notifies the private review agent of: 21
1. the admission of the patient; and 22
2. the reasons for the admission. 23
(2) A private review agent may not render an adverse decision as to an 24
admission of a patient to a hospital for up to 72 hours, as determined to be medically 25
necessary by the patient’s treating physician, when: 26
(i) the admission is an involuntary admission under §§ 10–615 and 27
10–617(a) of the Health – General Article; and 28
(ii) the hospital immediately notifies the private review agent of: 29
1. the admission of the patient; and 30
2. the reasons for the admission. 31
SENATE BILL 308 21
(e) (1) A private review agent that requires a health care provider to submit a 1
treatment plan in order for the private review agent to conduct utilization review of 2
proposed or delivered services for the treatment of a mental illness, emotional disorder, or 3
a substance abuse disorder: 4
(i) shall accept: 5
1. the uniform treatment plan form adopted by the 6
Commissioner under § 15–10B–03(d) of this subtitle as a properly submitted treatment 7
plan form; or 8
2. if a service was provided in another state, a treatment plan 9
form mandated by the state in which the service was provided; and 10
(ii) may not impose any requirement to: 11
1. modify the uniform treatment plan form or its content; or 12
2. submit additional treatment plan forms. 13
(2) A uniform treatment plan form submitted under the provisions of this 14
subsection: 15
(i) shall be properly completed by the health care provider; and 16
(ii) may be submitted by electronic transfer. 17
15–10B–07. 18
(a) (1) (I) Except as provided in [paragraphs (2) and (3) ] 19
SUBPARAGRAPHS (II) AND (III) of this [subsection] PARAGRAPH , all adverse decisions 20
shall be made by a physician, or a panel of other appropriate health care service reviewers 21
with at least one physician on the panel who is: 22
1. board certified or eligible in the same specialty as the 23
treatment under review; AND 24
2. KNOWLEDGEABLE OF AND HAS EXPERIENCE IN TH E 25
DIAGNOSIS AND TREATM ENT UNDER REVIEW . 26
[(2)] (II) When the health care service under review is a mental health or 27
substance abuse service, the adverse decision shall be made by a physician, or a panel of 28
other appropriate health care service reviewers with at least one physician, selected by the 29
private review agent who IS: 30
22 SENATE BILL 308
[(i)] 1. [is] board certified or eligible in the same specialty as the 1
treatment under review; or 2
[(ii)] 2. [is] actively practicing or has demonstrated expertise in 3
the substance abuse or mental health service or treatment under review. 4
[(3)] (III) When the health care service under review is a dental service, 5
the adverse decision shall be made by a licensed dentist, or a panel of other appropriate 6
health care service reviewers with at least one licensed dentist on the panel. 7
(2) A PHYSICIAN OR DENTIST WHO MAKES AN ADVERSE DECISION OR 8
PARTICIPATES ON THE PANEL THAT MAKES AN ADVERSE DECISION IN ACCORDANCE 9
WITH PARAGRAPH (1) OF THIS SUBSECTION S HALL HOLD A CURRENT , VALID, AND 10
UNRESTRICTED LICENSE TO PRACTICE MEDICINE OR DENTISTRY IN THE STATE. 11
(b) All adverse decisions shall be made by a physician or a panel of other 12
appropriate health care service reviewers who are not compensated by the private review 13
agent in a manner that violates § 19–705.1 of the Health – General Article or that deters 14
the delivery of medically appropriate care. 15
(c) Except as provided in subsection (d) of this section, if a course of treatment 16
has been preauthorized or approved for a patient, a private review agent may not 17
retrospectively render an adverse decision regarding the preauthorized or approved 18
services delivered to that patient. 19
(d) A private review agent may retrospectively render an adverse decision 20
regarding preauthorized or approved services delivered to a patient if: 21
(1) the information submitted to the private review agent regarding the 22
services to be delivered to the patient was fraudulent or intentionally misrepresentative; 23
(2) critical information requested by the private review agent regarding 24
services to be delivered to the patient was omitted such that the private review agent’s 25
determination would have been different had the agent known the critical information; or 26
(3) the planned course of treatment for the patient that was approved by 27
the private review agent was not substantially followed by the provider. 28
(e) If a course of treatment has been preauthorized or approved for a patient, a 29
private review agent may not revise or modify the specific criteria or standards used for the 30
utilization review to make an adverse decision regarding the services delivered to that 31
patient. 32
15–10B–11. 33
A private review agent may not: 34 SENATE BILL 308 23
(8) use criteria and standards to conduct utilization review [unless the 1
criteria and standards used by the private review agent are: 2
(i) objective; 3
(ii) clinically valid; 4
(iii) compatible with established principles of health care; or 5
(iv) flexible enough to allow deviations from norms when justified on 6
a case–by–case basis] THAT DO NOT CONFORM TO INFOR MATION SUBMITTED WIT H 7
THE CERTIFICATE APPL ICATION OF THE PRIVA TE REVIEW AGENT AS R EQUIRED 8
UNDER § 15–10B–05 OF THIS SUBTITLE ; or 9
15–10B–12. 10
(a) (1) A person who violates any provision of § 15–10B–11 of this subtitle is 11
guilty of a misdemeanor and on conviction is subject to a penalty not exceeding [$1,000] 12
$5,000. 13
(2) Each day a violation is continued after the first conviction is a separate 14
offense. 15
(b) In addition to the provisions of subsection (a) of this section, if any person 16
violates any provision of § 15–10B–11 of this subtitle, the Commissioner may: 17
(1) deny, suspend, or revoke the certificate to do business as a private 18
review agent; 19
(2) issue an order to cease and desist from acting as a private review agent 20
without holding a certificate issued under this subtitle; 21
(3) require a private review agent to make restitution to a patient who has 22
suffered actual economic damage because of the violation; and 23
(4) impose an administrative penalty of up to [$5,000] $10,000 for each 24
violation of any provision of this subtitle. 25
15–10B–16. 26
The Commissioner [may] SHALL establish reporting AND REVIEW requirements to: 27
(1) evaluate the effectiveness of private review agents; and 28
24 SENATE BILL 308
(2) determine if the utilization review programs are in compliance with the 1
provisions of this section and applicable regulations. 2
SECTION 2. AND BE IT FURTHER ENACTED, That the Maryland Health Care 3
Commission shall: 4
(1) in consultation with health care practitioners, payors of health care 5
services, and the State–designated health information exchange, develop findings and 6
recommendations for: 7
(i) revising the electronic process required under § 19–108.2 of the 8
Health – General Article, as enacted by Section 1 of this Act, for health care services to 9
achieve greater standardization and uniformity across payors to ease the burden of prior 10
authorization and other utilization management techniques for patients, providers, and 11
payors; 12
(ii) replacing the use of proprietary health plan web–based portals 13
with the adoption of uniform implementation specifications and standardization of 14
certification criteria for health care services, including the use of a single sign–on option 15
for payor and third–party administrator websites; and 16
(iii) a pilot program through the State –designated health 17
information exchange to implement items (i) and (ii) of this item; 18
(2) in consultation with the Maryland Department of Health, examine 19
requiring managed care organizations that participate in the Maryland Medical Assistance 20
Program to use the standardized electronic process recommended in item (1) of this section; 21
and 22
(3) on or before December 1, 2023, submit a report to the General 23
Assembly, in accordance with § 2–1257 of the State Government Article, of its findings and 24
recommendations, including draft legislation necessary to implement the pilot program. 25
SECTION 3. AND BE IT FURTHER ENACTED, That: 26
(a) The Maryland Health Care Commission and the M aryland Insurance 27
Administration, in consultation with health care practitioners and payors of health care 28
services, jointly shall conduct a study on the development of standards for the 29
implementation of payor programs to modify prior authorization requirements for 30
prescription drugs, medical care, and other health care services based on health care 31
practitioner–specific criteria. 32
(b) The study conducted under subsection (a) of this section shall include an 33
examination of: 34
(1) adjustments to payor prior authorization requirements based on a 35
health care practitioner’s: 36 SENATE BILL 308 25
(i) prior approval rates; 1
(ii) ordering and prescribing patterns; and 2
(iii) participation in a payor’s two–sided incentive arrangement or a 3
capitation program; and 4
(2) any other information or metrics necessary to implement the payor 5
programs. 6
(c) On or before December 1, 2023, the Maryland Health Care Commission and 7
Maryland Insurance Administration jointly shall submit a report to the General Assembly, 8
in accordance with § 2–1257 of the State Government Article, with the findings and 9
recommendations from the study, including recommendations for legislative initiatives 10
necessary for the establishment of payor programs modifying prior authorization 11
requirements based on health care practitioner–specific criteria. 12
SECTION 4. AND BE IT FURTHER ENACTED, That, on or before October 1, 2023, 13
the Maryland Insurance Administration, in consultation with the Health Education and 14
Advocacy Unit in the Maryland Office of the Attorney General, shall work with medical 15
associations or societies and consumer advocacy organizations to develop an education 16
campaign to educate the public on their rights under Maryland’s Health Care Appeals and 17
Grievance Law. 18
SECTION 5. AND BE IT FURTHER ENACTED, That Section 1 of this Act shall take 19
effect January 1, 2024. 20
SECTION 6. AND BE IT FURTHER ENACTED, That, except as provided in Section 21
5 of this Act, this Act shall take effect July 1, 2023. 22