EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*hb1085*
HOUSE BILL 1085
J5, J1 EMERGENCY BILL 4lr1807
CF 4lr1810
By: Delegate Cullison
Introduced and read first time: February 7, 2024
Assigned to: Health and Government Operations
A BILL ENTITLED
AN ACT concerning 1
Maryland Insurance Administration – Mental Health Parity and Addiction 2
Equity Reporting Requirements – Revisions and Sunset Repeal 3
FOR the purpose of altering certain reporting requirements on health insurance carriers 4
relating to compliance with the federal Mental Health Parity and Addiction Equity 5
Act; altering requirements for certain analyses of nonquantitative treatment 6
limitations required of health insurance carriers; establishing certain remedies the 7
Maryland Insurance Commissioner may use to enforce compliance with the 8
reporting requirements; repealing the requirement that the Commissioner use a 9
certain form for the reporting requirements; repealing the termination date for the 10
reporting requirements; and generally relating to health insurance carriers and 11
mental health parity and addiction equity reporting. 12
BY repealing and reenacting, with amendments, 13
Article – Insurance 14
Section 15–144 15
Annotated Code of Maryland 16
(2017 Replacement Volume and 2023 Supplement) 17
BY repealing 18
Chapter 211 of the Acts of the General Assembly of 2020 19
Section 2 and 3 20
BY repealing and reenacting, with amendments, 21
Chapter 211 of the Acts of the General Assembly of 2020 22
Section 4 23
BY repealing 24
Chapter 212 of the Acts of the General Assembly of 2020 25
Section 2 and 3 26
2 HOUSE BILL 1085
BY repealing and reenacting, with amendments, 1
Chapter 212 of the Acts of the General Assembly of 2020 2
Section 4 3
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 4
That the Laws of Maryland read as follows: 5
Article – Insurance 6
15–144. 7
(a) (1) In this section the following words have the meanings indicated. 8
(2) “Carrier” means: 9
(i) an insurer that holds a certificate of authority in the State and 10
provides health insurance in the State; 11
(ii) a health maintenance organization that is licensed to operate in 12
the State; 13
(iii) a nonprofit health service plan that is licensed to operate in the 14
State; or 15
(iv) any other person or organization that provides health benefit 16
plans subject to State insurance regulation. 17
(3) “Health benefit plan” means: 18
(i) for a large group or blanket plan, a health benefit plan as defined 19
in § 15–1401 of this title; 20
(ii) for a small group plan, a health benefit plan as defined in § 21
15–1201 of this title; 22
(iii) for an individual plan: 23
1. a health benefit plan as defined in § 15–1301(l) of this title; 24
or 25
2. an individual health benefit plan as defined in § 26
15–1301(o) of this title; 27
(iv) short–term limited duration insurance as defined in § 15–1301(s) 28
of this title; or 29
(v) a student health plan as defined in § 15–1318(a) of this title. 30 HOUSE BILL 1085 3
(4) “Medical/surgical benefits” has the meaning stated in 45 C.F.R. § 1
146.136(a) and 29 C.F.R. § 2590.712(a). 2
(5) “Mental health benefits” has the meaning stated in 45 C.F.R. § 3
146.136(a) and 29 C.F.R. § 2590.712(a). 4
(6) “Nonquantitative treatment limitation” means treatment limitations 5
as defined in 45 C.F.R. § 146.136(a) and 29 C.F.R. § 2590.712(a). 6
(7) “Parity Act” means the Paul Wellstone and Pete Domenici Mental 7
Health Parity and Addiction Equity Act of 2008, AS AMENDED , and ITS IMPLEMENTING 8
REGULATIONS , INCLUDING 45 C.F.R. § 146.136 and 29 C.F.R. § 2590.712 AND ANY 9
OTHER RELATED REGULA TIONS FOUND IN THE CODE OF FEDERAL REGULATIONS . 10
(8) “Parity Act classification” means: 11
(i) inpatient in–network benefits; 12
(ii) inpatient out–of–network benefits; 13
(iii) outpatient in–network benefits; 14
(iv) outpatient out–of–network benefits; 15
(v) prescription drug benefits; and 16
(vi) emergency care benefits. 17
(9) “PRODUCT” HAS THE MEANING STAT ED IN § 15–1309(A)(3) OF 18
THIS TITLE. 19
[(9)] (10) “Substance use disorder benefits” has the meaning stated in 45 20
C.F.R. § 146.136(a) and 29 C.F.R. § 2590.712(a). 21
(b) This section applies to a carrier that delivers or issues for delivery a health 22
benefit plan in the State. 23
(c) (1) On or before [March 1, 2022, and March 1, 2024] JULY 1, 2024, AND 24
EVERY 2 YEARS THEREAFTER , each carrier subject to this section shall[: 25
(i) identify the five health benefit plans with the highest enrollment 26
for each product offered by the carrier in the individual, small, and large group markets; 27
and 28
4 HOUSE BILL 1085
(ii)] submit a report to the Commissioner ON PRODUCTS 1
IDENTIFIED BY THE COMMISSIONER to demonstrate the carrier’s compliance with the 2
Parity Act. 3
(2) The report submitted under paragraph (1) of this subsection shall 4
include [the following information for the health benefit plans identified under item (1)(i) 5
of this subsection: 6
(i) a description of the process used to develop or select the medical 7
necessity criteria for mental health benefits and substance use disorder benefits and the 8
process used to develop or select the medical necessity criteria for medical and surgical 9
benefits; 10
(ii) for each Parity Act classification, identification of 11
nonquantitative treatment limitations that are applied to mental health benefits and 12
substance use disorder benefits and medical and surgical benefits; 13
(iii) identification of the description of the nonquantitative treatment 14
limitations identified under item (ii) of this paragraph in documents and instruments under 15
which the plan is established or operated; and 16
(iv)] the results of [the] A comparative analysis [as described under 17
subsections (d) and (e) of this section] CONDUCTED BY EACH CARRIER ON NO T LESS 18
THAN FOUR NONQUANT ITATIVE TREATMENT LIMITATION S SELECTED BY THE 19
COMMISSIONER IN ACCORDANCE WITH P ARAGRAPH (3) OF THIS SUBSECTION . 20
(3) IN SELECTING THE NONQ UANTITATIVE TREATMENT L IMITATIONS 21
REQUIRED TO BE INCLU DED IN EACH REPORTING PERIO D, THE COMMISSIONER : 22
(I) SHALL PRIORITIZE THE NONQUANTITATIVE TREATMENT 23
LIMITATIONS IDENTIFI ED BY THE COMMISSIONER AS HAVIN G THE GREATEST 24
IMPACT ON PATIENT AC CESS TO CARE; AND 25
(II) MAY TAKE INTO CONSID ERATION OTHER FACTOR S 26
DETERMINED RELE VANT BY THE COMMISSIONER , INCLUDING COMPLAINT TRENDS 27
AND WHETHER THE NONQUA NTITATIVE TREATMENT LIMITATION WAS SELEC TED 28
FOR A PREVIOUS REPORTING YEAR . 29
(d) (1) A carrier subject to this section shall conduct a comparative analysis 30
for the nonquantitative treatment limitations identified under subsection [(c)(2)(ii)] (C)(2) 31
of this section as nonquantitative treatment limitations are: 32
(i) written; and 33
(ii) in operation. 34 HOUSE BILL 1085 5
(2) The comparative analysis of the nonquantitative treatment limitations 1
identified under subsection [(c)(2)(ii)] (C)(2) of this section shall demonstrate that the 2
processes, strategies, evidentiary standards, or other factors used in applying [the medical 3
necessity criteria and] each SELECTED nonquantitative treatment limitation to mental 4
health benefits and substance use disorder benefits in each Parity Act classification are 5
comparable to, and are applied no more stringently than, the processes, strategies, 6
evidentiary standards, or other factors used in applying [the medical necessity criteria and] 7
each SELECTED nonquantitative treatment limitation to medical and surgical benefits 8
within the same Parity Act classification. 9
(3) REGARDLESS OF WHETHER IT WAS USED BEFORE T HE PARITY 10
ACT WAS ENACTED , A CARRIER SHALL PERFORM AND PROVIDE A COMPARATIV E 11
ANALYSIS FOR EACH PROCESS, STRATEGY, EVIDENTIARY STANDARD OR OTHER 12
FACTOR USED IN APPLYING A SELECTED NONQUANTITATIVE TREA TMENT 13
LIMITATION USED DURING A REPORT ING PERIOD AND REQUE STED BY THE 14
COMMISSIONER . 15
(e) In providing the analysis required under subsection (d) of this section, a 16
carrier shall: 17
(1) identify the factors used to determine that a nonquantitative treatment 18
limitation will apply to a benefit, including: 19
(i) the sources for the factors; 20
(ii) the factors that were considered but rejected; and 21
(iii) if a factor was given more weight than another, the reason for 22
the difference in weighting; 23
(2) identify and define the specific evidentiary standards used to define the 24
factors and any other evidence relied on in designing each nonquantitative treatment 25
limitation; 26
(3) include the results of the audits, reviews, and analyses performed on 27
the nonquantitative treatment limitations identified under subsection [(c)(2)(ii)] (C)(2) 28
AND (3) of this section to conduct the analysis required under subsection (d)(2) of this 29
section for the [plans] PRODUCTS as written; 30
(4) include the results of the audits, reviews, and analyses performed on 31
the nonquantitative treatment limitations identified under subsection [(c)(2)(ii)] (C)(2) 32
AND (3) of this section to conduct the analysis required under subsection (d)(2) of this 33
section for the [plans] PRODUCTS as in operation; 34
6 HOUSE BILL 1085
(5) identify the measures used to ensure comparable design and 1
application of nonquantitative treatment limitations that are implemented by the carrier 2
and any entity delegated by the carrier to manage mental health benefits, substance use 3
disorder benefits, or medical/surgical benefits on behalf of the carrier; 4
(6) disclose the specific findings and conclusions reached by the carrier that 5
indicate that the [health benefit plan] PRODUCT is in compliance with this section and the 6
Parity Act [and its implementing regulations, including 45 C.F.R. 146.136 and 29 C.F.R. 7
2590.712 and any other related federal regulations found in the Code of Federal 8
Regulations]; and 9
(7) identify the process used to comply with the Parity Act disclosure 10
requirements for mental health benefits, substance use disorder benefits, and 11
medical/surgical benefits, including: 12
(i) the criteria for a medical necessity determination; 13
(ii) reasons for a denial of benefits; and 14
(iii) in connection with a member’s request for group plan 15
information and for purposes of filing an internal coverage or grievance matter and appeals, 16
plan documents that contain information about processes, strategies, evidentiary 17
standards, and any other factors used to apply a nonquantitative treatment limitation. 18
[(f) On or before March 1, 2022, and March 1, 2024, each carrier subject to this 19
section shall submit a report for the health benefit plans identified under subsection (c)(1)(i) 20
of this section to the Commissioner on the following data for the immediately preceding 21
calendar year for mental health benefits, substance use disorder benefits, and 22
medical/surgical benefits by Parity Act classification: 23
(1) the frequency, reported by number and rate, with which the health 24
benefit plan received, approved, and denied prior authorization requests for mental health 25
benefits, substance use disorder benefits, and medical and surgical benefits in each Parity 26
Act classification during the immediately preceding calendar year; and 27
(2) the number of claims submitted for mental health benefits, substance 28
use disorder benefits, and medical and surgical benefits in each Parity Act classification 29
during the immediately preceding calendar year and the number and rates of, and reasons 30
for, denial of claims.] 31
(F) THE COMMISSIONER MAY DEVE LOP AND REQUIRE ADDI TIONAL 32
STANDARD IZED DATA SUBMISSION S TO EVALUATE A COMPARATIVE ANALYSIS OF 33
NONQUANTITATIVE TREA TMENT LIMITATIONS . 34
(g) The reports required under [subsections (c) and (f) of] this section shall: 35
HOUSE BILL 1085 7
(1) be submitted on a standard form THAT IS developed by the 1
Commissioner IN ACCORDANCE WITH C URRENT BEST PRACTICE S; 2
(2) be submitted by the carrier that issues or delivers the [health benefit 3
plan] PRODUCT; 4
(3) be prepared in coordination with any entity the carrier contracts with 5
to provide mental health benefits and substance use disorder benefits; 6
(4) contain a statement, signed by a corporate officer, attesting to the 7
accuracy of the information contained in the report; 8
(5) be available to plan members and the public on the carrier’s website in 9
a summary form that removes confidential or proprietary information and is developed by 10
the Commissioner [in accordance with subsection (m)(2) of this section]; and 11
(6) exclude any identifying information of any plan member. 12
(h) (1) A carrier submitting a report under [subsections (c) and (f) of] this 13
section may submit a written request to the Commissioner that disclosure of specific 14
information included in the report be denied under the Public Information Act and, if 15
submitting a request, shall: 16
(i) identify the particular information the disclosure of which the 17
carrier requests be denied; and 18
(ii) cite the statutory authority under the Public Information Act 19
that authorizes denial of access to the information. 20
(2) The Commissioner may review a request submitted under paragraph 21
(1) of this subsection on receipt of a request for access to the information under the Public 22
Information Act. 23
(3) The Commissioner may notify the carrier that submitted the request 24
under paragraph (1) of this subsection before granting access to information that was the 25
subject of the request. 26
(4) A carrier shall disclose to a member on request any plan information 27
contained in a report that is required to be disclosed to that member under federal or State 28
law. 29
(i) The Commissioner shall: 30
(1) review each report submitted in accordance with [subsections (c) and 31
(f) of] this section to assess each carrier’s compliance with the Parity Act; 32
8 HOUSE BILL 1085
(2) notify a carrier in writing of any noncompliance with the Parity Act 1
before issuing an administrative order; and 2
(3) within 90 days after the notice of noncompliance is issued, allow the 3
carrier to: 4
(i) submit a compliance plan to the Administration to comply with 5
the Parity Act; and 6
(ii) reprocess any claims that were improperly denied, in whole or in 7
part, because of the noncompliance. 8
(j) (1) If the Commissioner finds that the carrier failed to submit a complete 9
report required under [subsection (c) or (f) of] this section, the Commissioner may: 10
(I) TAKE ACTION AUTHORIZ ED UNDER PARAGRAPH (2) OF THIS 11
SUBSECTION; 12
(II) CHARGE THE CARRIER , IN ACCORDANCE WITH § 2–208 OF 13
THIS ARTICLE, FOR ANY ADDITIONAL E XPENSES INCURRED BY THE COMMISSIONER 14
AFTER THE COMMISSIONER DETERMIN ES THE INITIALLY SUBMITTED REPORT WAS 15
INCOMPLETE ; OR 16
(III) impose any penalty or take any action as authorized: 17
[(1)] 1. for an insurer, nonprofit health service plan, or any other 18
person subject to this section, under this article; or 19
[(2)] 2. for a health maintenance organization, under this article 20
or the Health – General Article. 21
(2) IF THE COMMISSIONER CANNOT M AKE A DETERMINATION THAT A 22
SPECIFIC CONDUCT OR PRACTICE IS COMPLIAN T WITH THE PARITY ACT BECAUSE 23
THE CARRIER FAILED T O PROVIDE A SUFFICIE NT COMPARATIVE ANALY SIS FOR A 24
NONQUANTITATIVE TREA TMENT LIMITATION , THE COMMISSIONER MAY : 25
(I) ISSUE AN ADMINISTRAT IVE ORDER REQUIRING THE 26
CARRIER OR AN ENTITY DELEGATED BY THE CAR RIER TO TAKE THE FOLLOWING 27
ACTION UNTIL THE COMMISSIONER CAN MAKE A DETERMINATION OF COMPLIANCE 28
WITH THE PARITY ACT: 29
1. MODIFY THE CONDUCT OR PRACT ICE AS SPECIFIED 30
BY THE COMMISSIONER ; 31
2. CEASE THE CONDUCT OR PRACTICE; OR 32 HOUSE BILL 1085 9
3. SUBMIT PERIODIC DATA RELATED TO THE CONDUCT 1
OR PRACTICE; OR 2
(II) SUBJECT TO PARAGRAPH (3) OF THIS SUBSECTION , 3
REQUIRE THE CARRIER TO PERFORM A NEW COM PARATIVE ANALYSIS . 4
(3) THE COMMISSIONER MAY REQU IRE THE CARRIER TO E STABLISH 5
SPECIFIC QUANTITATIV E THRESHOLDS FOR EVIDE NTIARY STANDARDS AND 6
CONDUCT A NEW COMPARATIVE AN ALYSIS FOR A NONQUANTITATIVE TR EATMENT 7
LIMITATION IF THE COMMISSIONER DETERMIN ES A CARRIER FAILED TO PROVIDE A 8
SUFFICIENT COMPARATI VE ANALYSIS BECAUSE THE CARRIER DID NOT: 9
(I) USE APPLICABLE QUANT ITATIVE THRESHOLDS FOR THE 10
EVIDENTIARY STANDARD ; OR 11
(II) PROVIDE A SPECIFIC , DETAILED, AND REASONED 12
EXPLANATION OF HOW T HE CARRIER ENSURES T HE FACTORS FOR THE 13
NONQUANTITATIVE TREA TMENT LIMITATION ARE BEING APPLIED CO MPARABLY 14
AND NO MORE STRINGEN TLY TO MENTAL HEALTH AND SUBSTANCE USE DISORDER 15
SERVICES. 16
(k) If, as a result of the review required under subsection (i)(1) of this section, the 17
Commissioner finds that the carrier failed to comply with the provisions of the Parity Act, 18
and did not submit a compliance plan to adequately correct the noncompliance, the 19
Commissioner may: 20
(1) issue an administrative order that requires: 21
(i) the carrier or an entity delegated by the carrier to cease the 22
noncompliant conduct or practice; or 23
(ii) the carrier to provide a payment that has been denied improperly 24
because of the noncompliance; or 25
(2) impose any penalty or take any action as authorized: 26
(i) for an insurer, nonprofit health service plan, or any other person 27
subject to this section, under this article; or 28
(ii) for a health maintenance organization, under this article or the 29
Health – General Article. 30
(l) In determining an appropriate penalty under subsection (j) or (k) of this 31
section, the Commissioner shall consider the late filing of a report required under 32 10 HOUSE BILL 1085
[subsection (c) or (f) of] this section and any parity violation to be a serious violation with 1
a significantly deleterious effect on the public. 2
[(m) On or before December 31, 2021, the Commissioner shall create: 3
(1) a standard form for entities to submit the reports in accordance with 4
subsection (g)(1) of this section; and 5
(2) a summary form for entities to post to their websites in accordance with 6
subsection (g)(5) of this section.] 7
(M) ON OR BEFORE JANUARY 1, 2026, AND EVERY 2 YEARS THEREAFTER , 8
THE COMMISSIONER SHALL SU BMIT A REPORT TO THE GENERAL ASSEMBLY, IN 9
ACCORDANCE WITH § 2–1257 OF THE STATE GOVERNMENT ARTICLE, THAT: 10
(1) SUMMARIZES THE FINDI NGS OF THE COMMISSIONER AFTER 11
REVIEWING THE REPORT S REQUIRED UNDER THIS SECTION; AND 12
(2) MAKES SPECIFIC RECOM MENDATIONS REGARDING : 13
(I) THE INFORMATION GAIN ED FROM THE REPORTS ; 14
(II) THE VALUE OF AND NEE D FOR ONGOING COMPLI ANCE AND 15
DATA REPORTING ; 16
(III) THE FREQUENCY OF REP ORTING IN SUBSEQUENT YEARS 17
AND WHETHER TO REPOR T ON AN ANNUAL OR BI ENNIAL BASIS; AND 18
(IV) BASED ON THE CARRIER REPORTS AND OTHER GU IDANCE 19
FROM FEDERAL REGULAT ORS AND OTHER STATES , ANY CHANGES IN THE 20
REPORTING AND DATA R EQUIREMENTS THAT SHO ULD BE IMPLEMENTED I N 21
SUBSEQUENT YEARS , INCLUDING FREQUENCY AND CONTENT AND WHET HER 22
ADDITIONAL NONQUANTI TATIVE TREATMENT LIM ITATIONS SHOULD BE I NCLUDED 23
IN THE REPORTING AND DATA REQUIREMENTS . 24
(n) [On or before December 31, 2021, the] THE Commissioner shall, in 25
consultation with interested stakeholders, adopt regulations to implement this section, 26
including to ensure uniform definitions and methodology for the reporting requirements 27
established under this section. 28
Chapter 211 of the Acts of 2020 29
[SECTION 2. AND BE IT FURTHER ENACTED, That the standard form the 30
Maryland Insurance Commissioner is required to develop under § 15–144(m)(1) of the 31
Insurance Article, as enacted by Section 1 of this Act, for the report required under § 32 HOUSE BILL 1085 11
15–144(c) of the Insurance Article, as enacted by Section 1 of this Act, shall be the National 1
Association of Insurance Commissioners’ Data Collection Tool for Mental Health Parity 2
Analysis, Nonquantitative Treatment Limitations and any ame ndments by the 3
Commissioner to the tool necessary to incorporate the requirements of § 15–144(c), (d), and 4
(e) of the Insurance Article, as enacted by Section 1 of this Act.] 5
[SECTION 3. AND BE IT FURTHER ENACTED, That the Maryland Insurance 6
Commissioner shall submit to the General Assembly an interim report on or before 7
December 1, 2023, and a final report on or before December 1, 2025, in accordance with § 8
2–1257 of the State Government Article, that: 9
(1) summarize the findings of the Commissioner after reviewing the 10
reports required under Section 1 of this Act; and 11
(2) make specific recommendations regarding: 12
(i) the information gained from the reports; 13
(ii) the value of and need for ongoing compliance and data reporting; 14
(iii) the frequency of reporting in subsequent years and whether to 15
report on an annual or biennial basis; and 16
(iv) based on the carrier reports and other guidance from federal 17
regulators and other states, any changes in the reporting and data requirements that 18
should be implemented in subsequent years, including frequency and content and whether 19
additional nonquantitative treatment limitations should be included in the reporting and 20
data requirements.] 21
SECTION 4. AND BE IT FURTHER ENACTED, Tha t this Act shall take effect 22
October 1, 2020. [It shall remain in effect for a period of 6 years and, at the end of 23
September 30, 2026, this Act, with no further action required by the General Assembly, 24
shall be abrogated and of no further force and effect.] 25
Chapter 212 of the Acts of 2020 26
[SECTION 2. AND BE IT FURTHER ENACTED, That the standard form the 27
Maryland Insurance Commissioner is required to develop under § 15–144(m)(1) of the 28
Insurance Article, as enacted by Section 1 of this Act, for the report required under § 29
15–144(c) of the Insurance Article, as enacted by Section 1 of this Act, shall be the National 30
Association of Insurance Commissioners’ Data Collection Tool for Mental Health Parity 31
Analysis, Nonquantitative Treatment Limitations and any amendments by the 32
Commissioner to the tool necessary to incorporate the requirements of § 15–144(c), (d), and 33
(e) of the Insurance Article, as enacted by Section 1 of this Act.] 34
12 HOUSE BILL 1085
[SECTION 3. AND BE IT FURTHER ENACTED, That the Maryland Insurance 1
Commissioner shall submit to the General Assembly an interim report on or before 2
December 1, 2023, and a final report on or before December 1, 2025, in accordance with § 3
2–1257 of the State Government Article, that: 4
(1) summarize the findings of the Commissioner after reviewing the 5
reports required under Section 1 of this Act; and 6
(2) make specific recommendations regarding: 7
(i) the information gained from the reports; 8
(ii) the value of and need for ongoing compliance and data reporting; 9
(iii) the frequency of reporting in subsequent years and whether to 10
report on an annual or biennial basis; and 11
(iv) based on the carrier reports and other guidance from federal 12
regulators and other states, any changes in the reporting and data requirements that 13
should be implemented in subsequent years, including frequency and content and whether 14
additional nonquantitative treatment limitations should be included in the reporting and 15
data requirements.] 16
SECTION 4. AND BE IT FURTHER ENACTED, That this Act shall take effect 17
October 1, 2020. [It shall remain in effect for a period of 6 years and, at the end of 18
September 30, 2026, this Act, with no further action required by the General Assembly, 19
shall be abrogated and of no further force and effect.] 20
SECTION 2. AND BE IT FURTHER ENACTED, That this Act is an emergency 21
measure, is necessary for the immediate preservation of the public health or safety, has 22
been passed by a yea and nay vote supported by three–fifths of all the members elected to 23
each of the two Houses of the General Assembly, and shall take effect from the date it is 24
enacted. 25