Maryland 2024 Regular Session

Maryland Senate Bill SB791 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	WES MOORE, Governor Ch. 848
2	1
3		-	– 1 –
4		-	Chapter 848
5		-	(Senate Bill 791)
6	2
7		-	AN ACT concerning
	3	+	EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
	4	+	[Brackets] indicate matter deleted from existing law.
	5	+	Underlining indicates amendments to bill.
	6	+	Strike out indicates matter stricken from the bill by amendment or deleted from the law by
	7	+	amendment.
	8	+	Italics indicate opposite chamber/conference committee amendments.
	9	+	sb0791
8	10
9		-	Health Insurance – Utilization Review – Revisions
	11	+	SENATE BILL 791
	12	+	J5, J4 (4lr2880)
	13	+	ENROLLED BILL
	14	+	— Finance/Health and Government Operations —
	15	+	Introduced by Senator Klausmeier
10	16
11		-	FOR the purpose of altering and establishing requirements and prohibitions related to
12		-	health insurance utilization review; altering requirements related to internal
13		-	grievance procedures and adverse decision procedures; altering certain reporting
14		-	requirements on health insurance carriers relating to adverse decisions; establishing
15		-	requirements on health insurance carriers and health care providers relating to the
16		-	provision of patient benefit information; and generally relating to health insurance
17		-	and utilization review.
	17	+	Read and Examined by Proofreaders:
18	18
19		-	BY adding to
20		-	Article – Health – General
21		-	Section 19–108.5
22		-	Annotated Code of Maryland
23		-	(2023 Replacement Volume)
	19	+	_______________________________________________
	20	+	Proofreader.
	21	+	_______________________________________________
	22	+	Proofreader.
24	23
25		-	BY repealing and reenacting, without amendments,
26		-	Article – Insurance
27		-	Section 15–851 and 15–10B–01(a)
28		-	Annotated Code of Maryland
29		-	(2017 Replacement Volume and 2023 Supplement)
	24	+	Sealed with the Great Seal and presented to the Governor, for his approval this
30	25
31		-	BY repealing and reenacting, with amendments,
32		-	Article – Insurance
33		-	Section 15–854 and 15–10B–06
34		-	Annotated Code of Maryland
35		-	(2017 Replacement Volume and 2023 Supplement)
36		-	(As enacted by Chapters 364 and 365 of the Acts of the General Assembly of 2023)
	26	+	_______ day of _______________ at _________________ _______ o’clock, ________M.
37	27
38		-	BY adding to
39		-	Article – Insurance
40		-	Section 15–854.1
41		-	Annotated Code of Maryland
42		-	(2017 Replacement Volume and 2023 Supplement)
	28	+	______________________________________________
	29	+	President.
43	30
44		-	BY repealing and reenacting, with amendments,
45		-	Article – Insurance
46		-	Section 15–10A–01, 15–10A–02, 15–10A–04(c), 15–10A–06, 15–10A–08,
47		-	15–10B–01(b), 15–10B–02, 15–10B–05, 15–10B–07, and 15–10B–09.1
48		-	Annotated Code of Maryland
49		-	(2017 Replacement Volume and 2023 Supplement) Ch. 848 2024 LAWS OF MARYLAND
	31	+	CHAPTER ______
50	32
51		-	~~– 2 –~~
	33	+	AN ACT concerning 1
52	34
53		-	SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND,
54		-	That the Laws of Maryland read as follows:
	35	+	Health Insurance – Utilization Review – Revisions 2
55	36
56		-	Article – Health – General
	37	+	FOR the purpose of altering and establishing requirements and prohibitions related to 3
	38	+	health insurance utilization review; altering requirements related to internal 4
	39	+	grievance procedures and adverse decision procedures; altering certain reporting 5
	40	+	requirements on health insurance carriers relating to adverse decisions; establishing 6
	41	+	requirements on health insurance carriers and health care providers relating to the 7
	42	+	provision of patient benefit information; and generally relating to health insurance 8
	43	+	and utilization review. 9
57	44
58		-	19–108.5.
	45	+	BY adding to 10
	46	+	Article – Health – General 11
	47	+	Section 19–108.5 12
	48	+	Annotated Code of Maryland 13
	49	+	(2023 Replacement Volume) 14 2 SENATE BILL 791
59	50
60		-	(A) (1) IN THIS SECTION THE F OLLOWING WORDS HAVE THE MEANINGS
61		-	INDICATED.
62	51
63		-	(2) “CARRIER” HAS THE MEANING STAT ED IN § 15–1301 OF THE
64		-	INSURANCE ARTICLE.
65	52
66		-	(3) “HEALTH CARE PROVIDER ” HAS THE MEANING STAT ED IN §
67		-	19–108.3 OF THIS SUBTITLE.
	53	+	BY repealing and reenacting, without amendments, 1
	54	+	Article – Insurance 2
	55	+	Section 15–851 and 15–10B–01(a) 3
	56	+	Annotated Code of Maryland 4
	57	+	(2017 Replacement Volume and 2023 Supplement) 5
68	58
69		-	(B) (1) ON OR BEFORE JULY 1, 2026, A CARRIER SHALL ESTA BLISH AND
70		-	MAINTAIN AN ONLINE P ROCESS THAT:
	59	+	BY repealing and reenacting, with amendments, 6
	60	+	Article – Insurance 7
	61	+	Section 15–854 and 15–10B–06 8
	62	+	Annotated Code of Maryland 9
	63	+	(2017 Replacement Volume and 2023 Supplement) 10
	64	+	(As enacted by Chapters 364 and 365 of the Acts of the General Assembly of 2023) 11
71	65
72		-	(I) LINKS DIRECTLY TO ALL E–PRESCRIBING SYSTEMS AND
73		-	ELECTRONIC HEALTH RE CORD SYSTEMS THAT US E THE NATIONAL COUNCIL FOR
74		-	PRESCRIPTION DRUG PROGRAMS SCRIPT STANDARD AND THE NATIONAL
75		-	COUNCIL FOR PRESCRIPTION DRUG PROGRAMS REAL TIME BENEFIT STANDARD;
	66	+	BY adding to 12
	67	+	Article – Insurance 13
	68	+	Section 15–854.1 14
	69	+	Annotated Code of Maryland 15
	70	+	(2017 Replacement Volume and 2023 Supplement) 16
76	71
77		-	(II) CAN ACCEPT ELECTRONIC PRIOR AUTHORIZATION
78		-	REQUESTS FROM A HEAL TH CARE PROVIDER ;
	72	+	BY repealing and reenacting, with amendments, 17
	73	+	Article – Insurance 18
	74	+	Section 15–10A–01, 15–10A–02, 15–10A–04(c), 15–10A–06, 15–10A–08, 19
	75	+	15–10B–01(b), 15–10B–02, 15–10B–05, 15–10B–07, and 15–10B–09.1 20
	76	+	Annotated Code of Maryland 21
	77	+	(2017 Replacement Volume and 2023 Supplement) 22
79	78
80		-	~~(III) CAN APPROVE ELECTRONI C PRIOR AUTHORIZATIO N~~
81		-	~~REQUESTS~~:
	79	+	SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 23
	80	+	That the Laws of Maryland read as follows: 24
82	81
83		-	1. FOR WHICH NO ADDITIONAL INFORMATION IS
84		-	NEEDED BY THE CARRIE R TO PROCESS THE PRI OR AUTHORIZATION REQ UEST;
	82	+	Article – Health – General 25
85	83
86		-	2. ~~FOR WHICH NO CLINICAL REVIEW IS REQUIRED ; AND~~
	84	+	19–108.5. 26
87	85
88		-	~~3. THAT MEET~~ THE ~~CARRIER ’S~~ ~~CRITERIA FOR~~
89		-	~~APPROVAL; AND~~
	86	+	(A) (1) IN THIS SECTION THE F OLLOWING WORDS HAVE THE MEANINGS 27
	87	+	INDICATED. 28
90	88
91		-	(IV) LINKS DIRECTLY TO REA L–TIME PATIENT OUT–OF–POCKET
92		-	COSTS, INCLUDING COPAYMENT , DEDUCTIBLE, AND COINSURANCE COST S, AND
93		-	MORE AFFORDABLE MEDI CATION ALTERNATIVES MADE AVAILABLE BY TH E
94		-	CARRIER.
95		-	WES MOORE, Governor Ch. 848
	89	+	(2) “CARRIER” HAS THE MEANING STAT ED IN § 15–1301 OF THE 29
	90	+	INSURANCE ARTICLE. 30
96	91
97		-	– 3 –
98		-	~~(2) A CARRIER MAY NOT :~~
	92	+	(3) “HEALTH CARE PROVIDER ” HAS THE MEANING STAT ED IN § 31
	93	+	19–108.3 OF THIS SUBTITLE. 32
99	94
100		-	(I) IMPOSE A FEE OR CHARG E ON A PERSON FOR AC CESSING
101		-	THE ONLINE PROCESS REQUIRED UNDER PARAG RAPH (1) OF THIS SUBSECTION ; OR
	95	+	(B) (1) ON OR BEFORE JULY 1, 2026, A CARRIER SHALL ESTA BLISH AND 33
	96	+	MAINTAIN AN ONLINE P ROCESS THAT: 34
	97	+	SENATE BILL 791 3
102	98
103		-	(II) ACCESS, WITHOUT HEALTH CARE PROVIDER CONSENT ,
104		-	HEALTH CARE PROVIDER DATA VIA THE ONLINE PROCESS OTHER THAN F OR THE
105		-	INSURED OR ENROLLEE .
106	99
107		-	(C) ON OR BEFORE JULY 1, 2025, A CARRIER SHALL :
	100	+	(I) LINKS DIRECTLY TO ALL E–PRESCRIBING SYSTEMS AND 1
	101	+	ELECTRONIC HEALTH RE CORD SYSTEMS THAT US E THE NATIONAL COUNCIL FOR 2
	102	+	PRESCRIPTION DRUG PROGRAMS SCRIPT STANDARD AND THE NATIONAL 3
	103	+	COUNCIL FOR PRESCRIPTION DRUG PROGRAMS REAL TIME BENEFIT STANDARD; 4
108	104
109		-	(1) ON REQUEST OF A HEALTH CARE PROVIDER , PROVIDE CONTACT
110		-	INFORMATION FOR EACH THIRD–PARTY VENDOR OR OTHE R ENTITY THAT THE
111		-	CARRIER WILL USE TO MEET THE REQUIREMENT S OF SUBSECTION (B) OF THIS
112		-	SECTION; AND
	105	+	(II) CAN ACCEPT ELECTRONIC PRIOR AUTHORIZATION 5
	106	+	REQUESTS FROM A HEAL TH CARE PROVIDER ; 6
113	107
114		-	(2) ~~POST THE CONTACT INFO RMATION REQUIRED TO BE PROVIDE D~~
115		-	~~UNDER ITEM (1) OF THIS SUBSECTION O N ITS WEBSITE.~~
	108	+	(III) CAN APPROVE ELECTRONI C PRIOR AUTHORIZATIO N 7
	109	+	REQUESTS: 8
116	110
117		-	(D) (1) ON OR BEFORE JULY 1, 2026, EACH HEALTH CARE PRO VIDER
118		-	SHALL ENSURE THAT EA CH E–PRESCRIBING SYSTEM O R ELECTRONIC HEALTH
119		-	RECORD SYSTEM OWNED OR CONTRACTED FOR BY THE HEALTH CARE PROV IDER TO
120		-	MAINTAIN A HEALTH RECORD OF AN INSURED OR ENROLL EE HAS THE ABILITY T O
121		-	ACCESS, AT THE POINT OF PRES CRIBING:
	111	+	1. FOR WHICH NO ADDITIONAL INFORMATION IS 9
	112	+	NEEDED BY THE CARRIE R TO PROCESS THE PRI OR AUTHORIZATION REQ UEST; 10
122	113
123		-	(I) THE ELECTRONIC PRIOR AUTHORIZATION PROCES S
124		-	ESTABLISHED BY A CAR RIER UNDER SUBSECTIO N (B) OF THIS SECTION; AND
	114	+	2. FOR WHICH NO CLINICAL REVIEW IS REQUIRED ; AND 11
125	115
126		-	(II) THE REAL –TIME PATIENT OUT–OF–POCKET COST
127		-	INFORMATION AND AVAI LABLE MEDICATION ALT ERNATIVES REQUIRED U NDER
128		-	SUBSECTION (B) OF THIS SECTION.
	116	+	3. THAT MEET THE CARRIER ’S CRITERIA FOR 12
	117	+	APPROVAL; AND 13
129	118
130		-	(2) THE COMMISSION SHALL ESTA BLISH BY REGULATION A PROCESS
131		-	THROUGH WHICH A HEAL TH CARE PROVIDER MAY REQUEST AND RECEIVE A WAIVER
132		-	OF COMPLIANCE FROM THE REQUI REMENTS OF THIS SUBS ECTION.
	119	+	(IV) LINKS DIRECTLY TO REA L–TIME PATIENT OUT–OF–POCKET 14
	120	+	COSTS, INCLUDING COPAYMENT , DEDUCTIBLE, AND COINSURANCE COST S, AND 15
	121	+	MORE AFFORDABLE MEDI CATION ALTERNATIVES MADE AVAILABLE BY TH E 16
	122	+	CARRIER. 17
133	123
134		-	(E) (1) ON OR BEFORE JULY 1, 2026, EACH CARRIER , OR A PHARMACY
135		-	BENEFITS MANAGER ON BEHALF OF THE CARRIE R, SHALL:
	124	+	(2) A CARRIER MAY NOT : 18
136	125
137		-	(I) PROVIDE REAL –TIME PATIENT –SPECIFIC BENEFIT
138		-	INFORMATION TO INSUR EDS AND ENROLLEES AN D CONTRACTED HEALTH CA RE
139		-	PROVIDERS, INCLUDING ANY OUT –OF–POCKET COSTS AND MOR E AFFORDABLE
140		-	MEDICATION ALTERNATI VES OR PRIOR AUTHORI ZATION REQUIREMENTS ; AND
141		-	Ch. 848 2024 LAWS OF MARYLAND
	126	+	(I) IMPOSE A FEE OR CHARG E ON A PERSON FOR AC CESSING 19
	127	+	THE ONLINE PROCESS REQUIRED UNDER PARAG RAPH (1) OF THIS SUBSECTION ; OR 20
142	128
143		-	~~– 4 –~~
144		-	~~(II) ENSURE THAT~~ THE ~~INFOR MATION PROVIDED UNDE R ITEM~~
145		-	~~(I) OF THIS PARAGRAPH IS ACCURATE~~.
	129	+	(II) ACCESS, WITHOUT HEALTH CARE PROVIDER CONSENT , 21
	130	+	HEALTH CARE PROVIDER DATA VIA THE ONLINE PROCESS OTHER THAN F OR THE 22
	131	+	INSURED OR ENROLLEE . 23
146	132
147		-	(2) EACH CARRIER, OR A PHARMACY BENEFI TS MANAGER ON BEHALF
148		-	OF THE CARRIER , SHALL MAKE AVAILABLE THE INFORMATION REQU IRED TO BE
149		-	PROVIDED UNDER PARAG RAPH (1) OF THIS SUBSECTION T O THE HEALTH CARE
150		-	PROVIDER AT THE POIN T OF PRESCRIBING IN AN ACCESSIBLE AND
151		-	UNDERSTANDAB LE FORMAT, SUCH AS THROUGH THE HEALTH CARE PROVIDER ’S
152		-	E–PRESCRIBING SYSTEM O R ELECTRONIC HEALTH RECORD SYSTEM THAT T HE
153		-	CARRIER, PHARMACY BENEFITS MA NAGER, OR DESIGNATED SUBCON TRACTOR HAS
154		-	ADOPTED THAT USES TH E NATIONAL COUNCIL FOR PRESCRIPTION DRUG
155		-	PROGRAM S SCRIPT STANDARD AND THE NATIONAL COUNCIL FOR PRESCRIPTION
156		-	DRUG PROGRAMS REAL TIME BENEFIT STANDARD FROM WHICH T HE HEALTH
157		-	CARE PROVIDER MAKES THE REQUEST .
	133	+	(C) ON OR BEFORE JULY 1, 2025, A CARRIER SHALL : 24
158	134
159		-	Article – Insurance
	135	+	(1) ON REQUEST OF A HEALTH CARE PROVIDER , PROVIDE CONTACT 25
	136	+	INFORMATION FOR EACH THIRD–PARTY VENDOR OR OTHE R ENTITY THAT THE 26
	137	+	CARRIER WILL USE TO MEET THE REQUIREMENT S OF SUBSECTION (B) OF THIS 27
	138	+	SECTION; AND 28
160	139
161		-	15–851.
	140	+	(2) POST THE CONTACT INFO RMATION REQUIRED TO BE PROVIDE D 29
	141	+	UNDER ITEM (1) OF THIS SUBSECTION O N ITS WEBSITE. 30
	142	+	4 SENATE BILL 791
162	143
163		-	(a) (1) This section applies to:
164	144
165		-	(i) insurers and nonprofit health service plans that provide coverage
166		-	for substance use disorder benefits or prescription drugs under individual, group, or
167		-	blanket health insurance policies or contracts that are issued or delivered in the State; and
	145	+	(D) (1) ON OR BEFORE JULY 1, 2026, EACH HEALTH CARE PRO VIDER 1
	146	+	SHALL ENSURE THAT EA CH E–PRESCRIBING SYSTEM O R ELECTRONIC HEALTH 2
	147	+	RECORD SYSTEM OWNED OR CONTRACTED FOR BY THE HEALTH CARE PROV IDER TO 3
	148	+	MAINTAIN A HEALTH RE CORD OF AN INSURED O R ENROLLEE HAS THE A BILITY TO 4
	149	+	ACCESS, AT THE POINT OF PRES CRIBING: 5
168	150
169		-	(ii) health maintenance organizations that provide coverage for
170		-	substance use disorder benefits or prescription drugs under individual or group contracts
171		-	that are issued or delivered in the State.
	151	+	(I) THE ELECTRONIC PRIOR AUTHORIZATION PROCES S 6
	152	+	ESTABLISHED BY A CAR RIER UNDER SUBSECTIO N (B) OF THIS SECTION; AND 7
172	153
173		-	(2) An insurer, a nonprofit health service plan, or a health maintenance
174		-	organization that provides coverage for substance use disorder benefits under the medical
175		-	benefit or for prescription drugs through a pharmacy benefits manager is subject to the
176		-	requirements of this section.
	154	+	(II) THE REAL –TIME PATIENT OUT–OF–POCKET COST 8
	155	+	INFORMATION AND AVAI LABLE MEDICATION ALT ERNATIVES REQUIRED U NDER 9
	156	+	SUBSECTION (B) OF THIS SECTION. 10
177	157
178		-	(b) An entity subject to this section may not apply a prior authorization
179		-	requirement for a prescription drug:
	158	+	(2) THE COMMISSION SHALL ESTA BLISH BY REGULATION A PROCESS 11
	159	+	THROUGH WHICH A HEAL TH CARE PROVIDER MAY REQUEST AND RECEIVE A WAIVER 12
	160	+	OF COMPLIANCE FROM THE REQUI REMENTS OF THIS SUBS ECTION. 13
180	161
181		-	(1) when used for treatment of an opioid use disorder; and
	162	+	(E) (1) ON OR BEFORE JULY 1, 2026, EACH CARRIER , OR A PHARMACY 14
	163	+	BENEFITS MANAGER ON BEHALF OF THE CARRIE R, SHALL: 15
182	164
183		-	(2) that contains methadone, buprenorphine, or naltrexone.
	165	+	(I) PROVIDE REAL –TIME PATIENT –SPECIFIC BENEFIT 16
	166	+	INFORMATION TO INSUR EDS AND ENROLLEES AN D CONTRACTED HEALTH CA RE 17
	167	+	PROVIDERS, INCLUDING ANY OUT –OF–POCKET COSTS AND MOR E AFFORDABLE 18
	168	+	MEDICATION ALTERNATI VES OR PRIOR AUTHORI ZATION REQUIREMENTS ; AND 19
184	169
185		-	15–854.
	170	+	(II) ENSURE THAT THE INFOR MATION PROVIDED UNDE R ITEM 20
	171	+	(I) OF THIS PARAGRAPH IS ACCURATE. 21
186	172
187		-	(a) (1) This section applies to:
188		-	WES MOORE, Governor Ch. 848
	173	+	(2) EACH CARRIER, OR A PHARMACY BENEFI TS MANAGER ON BEHALF 22
	174	+	OF THE CARRIER , SHALL MAKE AVAILABLE THE INFORMATION REQU IRED TO BE 23
	175	+	PROVIDED UNDER PARAG RAPH (1) OF THIS SUBSECTION T O THE HEALTH CARE 24
	176	+	PROVIDER AT THE POIN T OF PRESCRIBING IN AN ACCESSIBLE AND 25
	177	+	UNDERSTANDAB LE FORMAT, SUCH AS THROUGH THE HEALTH CARE PROVIDER ’S 26
	178	+	E–PRESCRIBING SYSTEM O R ELECTRONIC HEALTH RECORD SYSTEM THAT T HE 27
	179	+	CARRIER, PHARMACY BENEFITS MA NAGER, OR DESIGNATED SUBCON TRACTOR HAS 28
	180	+	ADOPTED THAT USES TH E NATIONAL COUNCIL FOR PRESCRIPTION DRUG 29
	181	+	PROGRAM S SCRIPT STANDARD AND THE NATIONAL COUNCIL FOR PRESCRIPTION 30
	182	+	DRUG PROGRAMS REAL TIME BENEFIT STANDARD FROM WHICH T HE HEALTH 31
	183	+	CARE PROVIDER MAKES THE REQUEST . 32
189	184
190		-	– 5 –
191		-	(i) insurers and nonprofit health service plans that provide coverage
192		-	for prescription drugs through a pharmacy benefit under individual, group, or blanket
193		-	health insurance policies or contracts that are issued or delivered in the State; and
	185	+	Article – Insurance 33
194	186
195		-	(ii) health maintenance organizations that provide coverage for
196		-	prescription drugs through a pharmacy benefit under individual or group contracts that
197		-	are issued or delivered in the State.
	187	+	15–851. 34
	188	+	SENATE BILL 791 5
198	189
199		-	(2) An insurer, a nonprofit health service plan, or a health maintenance
200		-	organization that provides coverage for prescription drugs through a pharmacy benefits
201		-	manager or that contracts with a private review agent under Subtitle 10B of this article is
202		-	subject to the requirements of this section.
203	190
204		-	(3) This section does not apply to a managed care organization as defined
205		-	in § 15–101 of the Health – General Article.
	191	+	(a) (1) This section applies to: 1
206	192
207		-	~~(b) (1)~~ (i) ~~If an entity subject to this section requires a prior authorization~~
208		-	for a prescription ~~drug~~, ~~the prior authorization request shall allow a health care provider~~
209		-	~~to indicate whether a prescription drug is to be used to treat a chronic condition.~~
	193	+	(i) insurers and nonprofit health service plans that provide coverage 2
	194	+	for substance use disorder benefits or prescription drugs under individual, group, or 3
	195	+	blanket health insurance policies or contracts that are issued or delivered in the State; and 4
210	196
211		-	(ii) If a health care provider indicates that the prescription drug is
212		-	to treat a chronic condition, an entity subject to this section may not request a
213		-	reauthorization for a repeat prescription for the prescription drug for 1 year or for the
214		-	standard course of treatment for the chronic condition being treated, whichever is less.
	197	+	(ii) health maintenance organizations that provide coverage for 5
	198	+	substance use disorder benefits or prescription drugs under individual or group contracts 6
	199	+	that are issued or delivered in the State. 7
215	200
216		-	(2) For a prior authorization that is filed electronically, the entity shall
217		-	maintain a database that will prepopulate prior authorization requests with an insured’s
218		-	available insurance and demographic information.
	201	+	(2) An insurer, a nonprofit health service plan, or a health maintenance 8
	202	+	organization that provides coverage for substance use disorder benefits under the medical 9
	203	+	benefit or for prescription drugs through a pharmacy benefits manager is subject to the 10
	204	+	requirements of this section. 11
219	205
220		-	(c) [If an entity subject to this section denies coverage for a prescription drug, the
221		-	entity shall provide a detailed written explanation for the denial of coverage, including
222		-	whether the denial was based on a requirement for prior authorization.
	206	+	(b) An entity subject to this section may not apply a prior authorization 12
	207	+	requirement for a prescription drug: 13
223	208
224		-	(d)] (1) On receipt of information documenting a prior authorization from the
225		-	insured or from the insured’s health care provider, an entity subject to this section shall
226		-	honor a prior authorization granted to an insured from a previous entity for at least the
227		-	[initial 30] LESSER OF 90 days [of an insured’s prescription drug benefit coverage under
228		-	the health benefit plan of the new entity] OR THE LENGTH OF THE COURSE OF
229		-	TREATMENT .
	209	+	(1) when used for treatment of an opioid use disorder; and 14
230	210
231		-	(2) During the time period described in paragraph (1) of this subsection, an
232		-	entity may perform its own review to grant a prior authorization for the prescription drug.
	211	+	(2) that contains methadone, buprenorphine, or naltrexone. 15
233	212
234		-	[(e)] (D) (1) An entity subject to this section shall honor a prior authorization
235		-	issued by the entity for a prescription drug AND MAY NOT REQUIRE A HEALTH CARE Ch. 848 2024 LAWS OF MARYLAND
	213	+	15–854. 16
236	214
237		-	– 6 –
238		-	PROVIDER TO SUBMIT A REQUEST FOR ANOTHER PRIOR AUTHORIZATION FOR THE
239		-	PRESCRIPTION DRUG :
	215	+	(a) (1) This section applies to: 17
240	216
241		-	(i) ~~if the insured changes~~ health ~~benefit~~ plans that ~~are both covered~~
242		-	~~by the same entity and the~~ prescription ~~drug is~~ a ~~covered~~ benefit under ~~the current health~~
243		-	~~benefit plan;~~ or
	217	+	(i) insurers and nonprofit health service plans that provide coverage 18
	218	+	for prescription drugs through a pharmacy benefit under individual, group, or blanket 19
	219	+	health insurance policies or contracts that are issued or delivered in the State; and 20
244	220
245		-	(ii) ~~except as provided in paragraph (2) of this subsection, when the~~
246		-	~~dosage for the approved~~ prescription ~~drug changes and the change is consistent with federal~~
247		-	~~Food and Drug Administration labeled dosages~~.
	221	+	(ii) health maintenance organizations that provide coverage for 21
	222	+	prescription drugs through a pharmacy benefit under individual or group contracts that 22
	223	+	are issued or delivered in the State. 23
248	224
249		-	(2) [An] EXCEPT AS PROVIDED IN § 15–851 OF THIS SUBTITLE , AN
250		-	entity may [not be required to honor] REQUIRE a prior authorization for a change in dosage
251		-	for an opioid under this subsection.
	225	+	(2) An insurer, a nonprofit health service plan, or a health maintenance 24
	226	+	organization that provides coverage for prescription drugs through a pharmacy benefits 25
	227	+	manager or that contracts with a private review agent under Subtitle 10B of this article is 26
	228	+	subject to the requirements of this section. 27
252	229
253		-	[(f)] (E) (1) If an entity under this section implements a new prior
254		-	authorization requirement for a prescription drug, the entity shall provide notice of the new
255		-	requirement at least [30] 60 days before the implementation of a new prior authorization
256		-	requirement:
	230	+	(3) This section does not apply to a managed care organization as defined 28
	231	+	in § 15–101 of the Health – General Article. 29
257	232
258		-	[(1)] (I) in writing to any insured who is prescribed the prescription drug;
259		-	and
	233	+	(b) (1) (i) If an entity subject to this section requires a prior authorization 30
	234	+	for a prescription drug, the prior authorization request shall allow a health care provider 31
	235	+	to indicate whether a prescription drug is to be used to treat a chronic condition. 32
	236	+	6 SENATE BILL 791
260	237
261		-	[(2)] (II) either in writing or electronically to all contracted health care
262		-	providers.
263	238
264		-	(2) THE ~~NOTICE REQUIRED U NDER PARAGRAPH (1) OF THIS~~
265		-	~~SUBSECTION SHALL IND ICATE THAT THE INSUR ED~~ MAY ~~REMAIN ON THE~~
266		-	PRESCRIPTION DRUG AT THE ~~TIME OF REAUTHOR IZATION IN ACCORDANC E WITH~~
267		-	~~SUBSECTION (G)~~ OF ~~THIS SECTION~~.
	239	+	(ii) If a health care provider indicates that the prescription drug is 1
	240	+	to treat a chronic condition, an entity subject to this section may not request a 2
	241	+	reauthorization for a repeat prescription for the prescription drug for 1 year or for the 3
	242	+	standard course of treatment for the chronic condition being treated, whichever is less. 4
268	243
269		-	~~[(g)] (F) (1) Except as provided in paragraph~~ (2) ~~of this subsection~~, an entity
270		-	~~subject to this section may not require more than one~~ prior authorization ~~if two or more~~
271		-	~~tablets of different dosage strengths of the same prescription drug are:~~
	244	+	(2) For a prior authorization that is filed electronically, the entity shall 5
	245	+	maintain a database that will prepopulate prior authorization requests with an insured’s 6
	246	+	available insurance and demographic information. 7
272	247
273		-	(i) prescribed at the same time as part of an insured’s treatment
274		-	plan; and
	248	+	(c) [If an entity subject to this section denies coverage for a prescription drug, the 8
	249	+	entity shall provide a detailed written explanation for the denial of coverage, including 9
	250	+	whether the denial was based on a requirement for prior authorization. 10
275	251
276		-	(ii) manufactured by the same manufacturer.
	252	+	(d)] (1) On receipt of information documenting a prior authorization from the 11
	253	+	insured or from the insured’s health care provider, an entity subject to this section shall 12
	254	+	honor a prior authorization granted to an insured from a previous entity for at least the 13
	255	+	[initial 30] LESSER OF 90 days [of an insured’s prescription drug benefit coverage under 14
	256	+	the health benefit plan of the new entity] OR THE LEN GTH OF THE COURSE OF 15
	257	+	TREATMENT . 16
277	258
278		-	(2) This subsection does not prohibit an entity from requiring more than
279		-	one prior authorization if the prescription is for two or more tablets of different dosage
280		-	strengths of an opioid that is not an opioid partial agonist.
281		-	WES MOORE, Governor Ch. 848
	259	+	(2) During the time period described in paragraph (1) of this subsection, an 17
	260	+	entity may perform its own review to grant a prior authorization for the prescription drug. 18
282	261
283		-	– 7 –
284		-	(G) (1) THIS SUBSECTION DOES NOT APPLY WITH RESPE CT TO A
285		-	REAUTHORIZATION OF A PRESCRIPTION DRUG RE QUESTED BY A PROVIDE R
286		-	EMPLOYED BY A GROUP MODEL HEALTH MAINTEN ANCE ORGANIZATION , AS DEFINED
287		-	IN § 19–713.6 OF THE HEALTH – GENERAL ARTICLE.
	262	+	[(e)] (D) (1) An entity subject to this section shall honor a prior authorization 19
	263	+	issued by the entity for a prescription drug AND MAY NOT REQUIRE A HEALTH CARE 20
	264	+	PROVIDER TO SUBMIT A REQUEST FOR ANOTHER PRIOR AUTHORIZATION FOR THE 21
	265	+	PRESCRIPTION DRUG : 22
288	266
289		-	(2) AN ENTITY SUBJEC T TO THIS SECTION MA Y NOT ISSUE AN
290		-	ADVERSE DECISION ON A REAUTHORIZATION FO R THE SAME PRESCRIPT ION DRUG
291		-	OR REQUEST ADDITIONA L DOCUMENTATION FROM THE PRESCRIBER FOR T HE
292		-	REAUTHORIZATION REQU EST IF:
	267	+	(i) if the insured changes health benefit plans that are both covered 23
	268	+	by the same entity and the prescription drug is a covered benefit under the current health 24
	269	+	benefit plan; or 25
293	270
294		-	(I) THE PRESCRIPTION DRU G IS A BIOLOGICAL PRODUCT USED
295		-	FOR IMMUNOTHERAPY OR :
	271	+	(ii) except as provided in paragraph (2) of this subsection, when the 26
	272	+	dosage for the approved prescription drug changes and the change is consistent with federal 27
	273	+	Food and Drug Administration labeled dosages. 28
296	274
297		-	1. AN IMMUNE GLOBULIN (HUMAN) AS DEFINED IN 21
298		-	C.F.R. § 640.100; OR
	275	+	(2) [An] EXCEPT AS PROVIDED IN § 15–851 OF THIS SUBTITLE , AN 29
	276	+	entity may [not be required to honor] REQUIRE a prior authorization for a change in dosage 30
	277	+	for an opioid under this subsection. 31
299	278
300		-	2. USED FOR THE TREATMENT OF A MENTAL DISORDER
301		-	LISTED IN THE MOST R ECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL
302		-	MANUAL OF MENTAL DISORDERS PUBLISHED B Y THE AMERICAN PSYCHIATRIC
303		-	ASSOCIATION;
	279	+	[(f)] (E) (1) If an entity under this section implements a new prior 32
	280	+	authorization requirement for a prescription drug, the entity shall provide notice of the new 33
	281	+	requirement at least [30] 60 days before the implementation of a new prior authorization 34
	282	+	requirement: 35
	283	+	SENATE BILL 791 7
304	284
305		-	(I) (II) THE ENTITY PREVIOUSL Y APPROVED A PRIOR
306		-	AUTHORIZATION FOR TH E PRESCRIPTION DRUG FOR THE INSURED ;
307	285
308		-	(II) (III) THE INSURED HAS BEEN TREATED WITH THE
309		-	PRESCRIPTION DRUG WI THOUT INTERRUPTION S INCE THE INITIAL APPROVAL OF
310		-	THE PRIOR AUTHORIZAT ION; AND
	286	+	[(1)] (I) in writing to any insured who is prescribed the prescription drug; 1
	287	+	and 2
311	288
312		-	(III) (IV) THE PRESCRIBER ATTES TS THAT, BASED ON THE
313		-	PRESCRIBER’S PROFESSIONAL JUDGM ENT, THE PRESCRIPTION DRU G CONTINUES
314		-	TO BE NECESSARY TO E FFECTIVELY TREAT THE INSURED’S CONDITION.
	289	+	[(2)] (II) either in writing or electronically to all contracted health care 3
	290	+	providers. 4
315	291
316		-	(3) (2) IF THE PRESCRIPTION DRUG THAT IS BEING REQUESTED H AS
317		-	BEEN REMOVED FROM TH E FORMULARY OR HAS B EEN MOVED TO A HIGHE R
318		-	DEDUCTIBLE, COPAYMENT , OR COINSURANCE TIER , THE ENTITY SHALL PRO VIDE
319		-	THE INSURED AND INSU RED’S HEALTH CARE PROVID ER THE INFORMATION
320		-	REQUIRED UNDER § 15–831 OF THIS SUBTITLE .
	292	+	(2) THE NOTICE REQUIRED U NDER PARAGRAPH (1) OF THIS 5
	293	+	SUBSECTION SHALL IND ICATE THAT THE INSUR ED MAY REMAIN ON THE 6
	294	+	PRESCRIPTION DRUG AT THE TIME OF REAUTHOR IZATION IN ACCORDANC E WITH 7
	295	+	SUBSECTION (G) OF THIS SECTION. 8
321	296
322		-	15–854.1.
	297	+	[(g)] (F) (1) Except as provided in paragraph (2) of this subsection, an entity 9
	298	+	subject to this section may not require more than one prior authorization if two or more 10
	299	+	tablets of different dosage strengths of the same prescription drug are: 11
323	300
324		-	(A) (1) IN THIS SECTION THE F OLLOWING WORDS HAVE THE MEANINGS
325		-	INDICATED.
326		-	Ch. 848 2024 LAWS OF MARYLAND
	301	+	(i) prescribed at the same time as part of an insured’s treatment 12
	302	+	plan; and 13
327	303
328		-	– 8 –
329		-	(2) “ACTIVE COURSE OF TREA TMENT” MEANS A COURSE OF
330		-	TREATMENT FOR WHICH AN INSURED IS ACTIVE LY SEEING A HEALTH C ARE
331		-	PROVIDER AND FOLLOWI NG THE COURSE OF TREATMENT .
	304	+	(ii) manufactured by the same manufacturer. 14
332	305
333		-	(3) “COURSE OF TREATMENT ” MEANS TREATMENT THAT :
	306	+	(2) This subsection does not prohibit an entity from requiring more than 15
	307	+	one prior authorization if the prescription is for two or more tablets of different dosage 16
	308	+	strengths of an opioid that is not an opioid partial agonist. 17
334	309
335		-	(I) IS PRESCRIBED TO TRE AT OR ORDERED FOR TH E
336		-	TREATMENT OF AN INSU RED WITH A SPECIFIC CONDITION;
	310	+	(G) (1) THIS SUBSECTION DOES NOT APPLY WITH RESPE CT TO A 18
	311	+	REAUTHORIZATION OF A PRESCRIPTION DRUG RE QUESTED BY A PROVIDE R 19
	312	+	EMPLOYED BY A GROUP MODEL HEALTH MAINTEN ANCE ORGANIZATION , AS DEFINED 20
	313	+	IN § 19–713.6 OF THE HEALTH – GENERAL ARTICLE. 21
337	314
338		-	(II) IS OUTLINED AND AGRE ED TO BY THE INSURED AND THE
339		-	HEALTH CARE PROVIDER BEFORE THE TREATMENT BEG INS; AND
	315	+	(2) AN ENTITY SUBJECT TO THIS SECT ION MAY NOT ISSUE AN 22
	316	+	ADVERSE DECISION ON A REAUTHORIZATION FO R THE SAME PRESCRIPT ION DRUG 23
	317	+	OR REQUEST ADDITIONA L DOCUMENTATION FROM THE PRESCRIBER FOR T HE 24
	318	+	REAUTHORIZATION REQU EST IF: 25
340	319
341		-	(III) MAY BE PART OF A TRE ATMENT PLAN .
	320	+	(I) THE PRESCRIPTION DRU G IS A BIOLOGICAL PRODUCT USED 26
	321	+	FOR IMMUNOTHERAPY OR : 27
342	322
343		-	(B) (1) THIS SECTION APPLIES TO:
	323	+	1. AN IMMUNE GLOBULIN (HUMAN) AS DEFINED IN 21 28
	324	+	C.F.R. § 640.100; OR 29
344	325
345		-	(I) INSURERS AND NONPROF IT HEALTH SERVICE PL ANS THAT
346		-	PROVIDE HOSPITAL , MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GR OUPS
347		-	ON AN EXPENSE–INCURRED BASIS UNDER HEALTH INSURANCE POL ICIES OR
348		-	CONTRACTS THAT ARE I SSUED OR DELIVERED I N THE STATE; AND
	326	+	2. USED FOR THE TREATMENT OF A MENTAL DISORDER 30
	327	+	LISTED IN THE MOST R ECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL 31
	328	+	MANUAL OF MENTAL DISORDERS PUBLISHED BY THE AMERICAN PSYCHIATRIC 32
	329	+	ASSOCIATION; 33
	330	+	8 SENATE BILL 791
349	331
350		-	(II) HEALTH MAINTENANCE O RGANIZATIONS THAT PR OVIDE
351		-	HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GR OUPS UNDER
352		-	CONTRACTS THAT ARE ISSUED OR DELIVE RED IN THE STATE.
353	332
354		-	(2) AN INSURER, A NONPROFIT HEALTH S ERVICE PLAN, OR A HEALTH
355		-	MAINTENANCE ORGANIZA TION THAT CONTRACTS WITH A PRIVATE REVIE W AGENT
356		-	UNDER SUBTITLE 10B OF THIS TITLE IS SUB JECT TO THE REQUIREM ENTS OF THIS
357		-	SECTION.
	333	+	(I) (II) THE ENTITY PREVIOUSL Y APPROVED A PRIOR 1
	334	+	AUTHORIZATION FOR TH E PRESCRIPTION DRUG FOR THE INSURED ; 2
358	335
359		-	(3) AN INSURER, A NONPROFIT HEALTH S ERVICE PLAN, OR A HEALTH
360		-	MAINTENANCE ORGANIZA TION THAT CONTRACTS WITH A THIRD PARTY T O
361		-	DISPENSE MEDICAL DEV ICES, MEDICAL APPLIANCES , OR MEDICAL GOODS FOR THE
362		-	TREATMENT OF A HUMAN DISEASE OR DYSFUNCTI ON IS SUBJECT TO THE
363		-	REQUIREMENTS OF THIS S ECTION.
	336	+	(II) (III) THE INSURED HAS BEEN TREATED WITH THE 3
	337	+	PRESCRIPTION DRUG WI THOUT INTERRUPTION S INCE THE INITIAL APPROVAL OF 4
	338	+	THE PRIOR AUTHORIZAT ION; AND 5
364	339
365		-	(C) (1) NOTWITHSTANDING § 15–854 OF THIS SUBTITLE AS IT APPLIES TO
366		-	COVERAGE FOR PRESCRI PTION DRUGS , AN ENTITY SUBJECT TO THIS SECTION
367		-	SHALL APPROVE A REQU EST FOR THE PRIOR AU THORIZATION OF A COU RSE OF
368		-	TREATMENT , INCLUDING FOR CHRONIC CONDITIONS , REHABILITATIVE SERVI CES,
369		-	SUBSTANCE USE DISORD ERS, AND MENTAL HEALTH CO NDITIONS, THAT IS:
370		-	WES MOORE, Governor Ch. 848
	340	+	(III) (IV) THE PRESCRIBER ATTES TS THAT, BASED ON THE 6
	341	+	PRESCRIBER’S PROFESSIONAL JUDGM ENT, THE PRESCRIPTION DRU G CONTINUES 7
	342	+	TO BE NECESSARY TO E FFECTIVELY TREAT THE INSURED’S CONDITION. 8
371	343
372		-	– 9 –
373		-	(I) FOR A PERIOD OF TIME THAT IS AS LONG AS N ECESSARY TO
374		-	AVOID DISRUPTIONS IN CARE; AND
	344	+	(3) (2) IF THE PRESCRIPTION DRUG TH AT IS BEING REQUESTE D HAS 9
	345	+	BEEN REMOVED FROM TH E FORMULARY OR HAS B EEN MOVED TO A HIGHE R 10
	346	+	DEDUCTIBLE, COPAYMENT , OR COINSURANCE TIER , THE ENTITY SHALL PRO VIDE 11
	347	+	THE INSURED AND INSU RED’S HEALTH CARE PROVID ER THE INFORMATION 12
	348	+	REQUIRED UNDER § 15–831 OF THIS SUBTITLE . 13
375	349
376		-	(II) DETERMINED IN ACCORD ANCE WITH APPLICABLE
377		-	COVERAGE CRITERIA, THE INSURED’S MEDICAL HISTORY , AND THE HEALTH CARE
378		-	PROVIDER’S RECOMMENDATION .
	350	+	15–854.1. 14
379	351
380		-	(2) FOR NEW ENROLLEES , AN ENTITY SUBJECT TO THIS SECTION MAY
381		-	NOT DISRUPT OR REQUI RE REAUTHORIZATION F OR AN ACTIVE COURSE OF
382		-	TREATMENT FOR COVERED SERVICES FOR AT LEAST 90 DAYS AFTER THE DATE OF
383		-	ENROLLMENT .
	352	+	(A) (1) IN THIS SECTION THE F OLLOWING WORDS HAVE THE MEANINGS 15
	353	+	INDICATED. 16
384	354
385		-	15–10A–01.
	355	+	(2) “ACTIVE COURSE OF TREA TMENT” MEANS A COURSE OF 17
	356	+	TREATMENT FOR WHICH AN INSURED IS ACTIVE LY SEEING A HEALTH C ARE 18
	357	+	PROVIDER AND FOLLOWI NG THE COURSE OF TREATMENT . 19
386	358
387		-	(a) ~~In this subtitle the following words have the meanings indicated.~~
	359	+	(3) “COURSE OF TREATMENT ” MEANS TREATMENT THAT : 20
388	360
389		-	(b) (1) “Adverse decision” means:
	361	+	(I) IS PRESCRIBED TO TRE AT OR ORDERED FOR TH E 21
	362	+	TREATMENT OF AN INSU RED WITH A SPECIFIC CONDITION; 22
390	363
391		-	(i) ~~a utilization review determination~~ by ~~a private review agent,~~ a
392		-	~~carrier, or a~~ health care provider ~~acting on behalf of a carrier that:~~
	364	+	(II) IS OUTLINED AND AGRE ED TO BY THE INSURED AND THE 23
	365	+	HEALTH CARE PROVIDER BEFORE THE TREATMENT BEGINS; AND 24
393	366
394		-	1. a proposed or delivered health care service covered under
395		-	the member’s contract is or was not medically necessary, appropriate, or efficient; and
	367	+	(III) MAY BE PART OF A TRE ATMENT PLAN . 25
396	368
397		-	~~2. may result in noncoverage of the health care service; or~~
	369	+	(B) (1) THIS SECTION APPLIES TO: 26
398	370
399		-	(ii) a denial by a carrier of a request by a member for an alternative
400		-	standard or a waiver of a standard to satisfy the requirements of a wellness program under
401		-	§ 15–509 of this title.
	371	+	(I) INSURERS AND NONPROF IT HEALTH SERVICE PL ANS THAT 27
	372	+	PROVIDE HOSPITAL , MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GR OUPS 28
	373	+	ON AN EXPENSE –INCURRED BASIS UNDER HEALTH INSURANCE POL ICIES OR 29
	374	+	CONTRACTS THAT ARE I SSUED OR DELIVERED I N THE STATE; AND 30
	375	+	SENATE BILL 791 9
402	376
403		-	(2) “ADVERSE DECISION ” INCLUDES A UTILIZATI ON REVIEW
404		-	DETERMINATION BASED ON A PRIOR AUTHORIZA TION OR STEP THERAPY
405		-	REQUIREMENT .
406	377
407		-	[(2)] (3) “Adverse decision” does not include a decision concerning a
408		-	subscriber’s status as a member.
	378	+	(II) HEALTH MAINTENANCE O RGANIZATIONS THAT PR OVIDE 1
	379	+	HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GR OUPS UNDER 2
	380	+	CONTRACTS THAT ARE I SSUED OR DELIVERED IN TH E STATE. 3
409	381
410		-	(c) “Carrier” means a person that offers a health benefit plan and is:
	382	+	(2) AN INSURER, A NONPROFIT HEALTH S ERVICE PLAN, OR A HEALTH 4
	383	+	MAINTENANCE ORGANIZA TION THAT CONTRACTS WITH A PRIVATE REVIE W AGENT 5
	384	+	UNDER SUBTITLE 10B OF THIS TITLE IS SUB JECT TO THE REQUIREM ENTS OF THIS 6
	385	+	SECTION. 7
411	386
412		-	(1) an authorized insurer that provides health insurance in the State;
	387	+	(3) AN INSURER, A NONPROFIT HEALTH S ERVICE PLAN, OR A HEALTH 8
	388	+	MAINTENANCE ORGANIZA TION THAT CONTRACTS WITH A THIRD PARTY T O 9
	389	+	DISPENSE MEDICAL DEV ICES, MEDICAL APPLIANCES , OR MEDICAL GOODS FOR THE 10
	390	+	TREATMENT OF A HUMAN DISEASE OR DYSFUNCTI ON IS SUBJECT TO THE 11
	391	+	REQUIREMENT S OF THIS SECTION. 12
413	392
414		-	(2) a nonprofit health service plan;
	393	+	(C) (1) NOTWITHSTANDING § 15–854 OF THIS SUBTITLE AS IT APPLIES TO 13
	394	+	COVERAGE FOR PRESCRI PTION DRUGS , AN ENTITY SUBJECT TO THIS SECTION 14
	395	+	SHALL APPROVE A REQU EST FOR THE PRIOR AU THORIZATION OF A COU RSE OF 15
	396	+	TREATMENT , INCLUDING FOR CHRONI C CONDITIONS, REHABILITATIVE SERVI CES, 16
	397	+	SUBSTANCE USE DISORD ERS, AND MENTAL HEALTH CO NDITIONS, THAT IS: 17
415	398
416		-	(3) a ~~health maintenance organization;~~
417		-	~~Ch.~~ ~~848~~ ~~2024 LAWS OF MARYLAND~~
	399	+	(I) FOR A PERIOD OF TIME THAT IS AS LONG AS N ECESSARY TO 18
	400	+	AVOID DISRUPTIONS IN CARE; AND 19
418	401
419		-	– 10 –
420		-	(4) a dental plan organization;
	402	+	(II) DETERMINED IN ACCORD ANCE WITH APPLICABLE 20
	403	+	COVERAGE CRITERIA, THE INSURED’S MEDICAL HISTORY , AND THE HEALTH CARE 21
	404	+	PROVIDER’S RECOMMENDATION . 22
421	405
422		-	(5) a self–funded student health plan operated by an indep endent
423		-	institution of higher education, as defined in § 10–101 of the Education Article, that
424		-	provides health care to its students and their dependents; or
	406	+	(2) FOR NEW ENROLLEES , AN ENTITY SUBJECT TO THIS SECTION MAY 23
	407	+	NOT DISRUPT OR REQUI RE REAUTHORIZATION F OR AN ACTIVE COURSE OF 24
	408	+	TREATMENT FOR COVERED SERVICES FOR AT LEAST 90 DAYS AFTER THE DATE OF 25
	409	+	ENROLLMENT . 26
425	410
426		-	(6) except for a managed care organization as defined in Title 15, Subtitle
427		-	1 of the Health – General Article, any other person that provides health benefit plans
428		-	subject to regulation by the State.
	411	+	15–10A–01. 27
429	412
430		-	(d) “Complaint” means a protest filed with the Commissioner involving an
431		-	adverse decision or grievance decision concerning the member.
	413	+	(a) In this subtitle the following words have the meanings indicated. 28
432	414
433		-	(e) “Designee of the Commissioner” means any person to whom the Commissioner
434		-	has delegated the authority to review and decide complaints filed under this subtitle,
435		-	including an administrative law judge to whom the authority to conduct a hearing has been
436		-	delegated for recommended or final decision.
	415	+	(b) (1) “Adverse decision” means: 29
437	416
438		-	(f) “Grievance” means a protest filed by a member, a member’s representative, or
439		-	a health care provider on behalf of a member with a carrier through the carrier’s internal
440		-	grievance process regarding an adverse decision concerning the member.
	417	+	(i) a utilization review determination by a private review agent, a 30
	418	+	carrier, or a health care provider acting on behalf of a carrier that: 31
441	419
442		-	~~(g) “Grievance decision” means~~ a ~~final determination by a carrier that arises from~~
443		-	~~a grievance filed with~~ the ~~carrier under its internal grievance process regarding an adverse~~
444		-	~~decision concerning a member.~~
	420	+	1. a proposed or delivered health care service covered under 32
	421	+	the member’s contract is or was not medically necessary, appropriate, or efficient; and 33
	422	+	10 SENATE BILL 791
445	423
446		-	(h) “Health Advocacy Unit” means the Health Education and Advocacy Unit in
447		-	the Division of Consumer Protection of the Office of the Attorney General established under
448		-	Title 13, Subtitle 4A of the Commercial Law Article.
449	424
450		-	~~(i) “Health~~ ~~benefit plan”~~ ~~has~~ the ~~meaning stated in § 2–112.2(a) of this article.~~
	425	+	2. may result in noncoverage of the health care service; or 1
451	426
452		-	(j) “Health care provider” means:
	427	+	(ii) a denial by a carrier of a request by a member for an alternative 2
	428	+	standard or a waiver of a standard to satisfy the requirements of a wellness program under 3
	429	+	§ 15–509 of this title. 4
453	430
454		-	(1) ~~an individual who is licensed under the Health Occupations Article to~~
455		-	~~provide health care services in the ordinary course of business~~ or ~~practice of a profession~~
456		-	~~and is a treating provider of the member; or~~
	431	+	(2) “ADVERSE DECISION ” INCLUDES A UTILIZATI ON REV IEW 5
	432	+	DETERMINATION BASED ON A PRIOR AUTHORIZA TION OR STEP THERAPY 6
	433	+	REQUIREMENT . 7
457	434
458		-	(2) a hospital, as defined in § 19–301 of the Health – General Article.
	435	+	[(2)] (3) “Adverse decision” does not include a decision concerning a 8
	436	+	subscriber’s status as a member. 9
459	437
460		-	(k) “Health care service” means a health or medical care procedure or service
461		-	rendered by a health care provider that:
	438	+	(c) “Carrier” means a person that offers a health benefit plan and is: 10
462	439
463		-	(1) provides testing, diagnosis, or treatment of a human disease or
464		-	dysfunction; [or]
465		-	WES MOORE, Governor Ch. 848
	440	+	(1) an authorized insurer that provides health insurance in the State; 11
466	441
467		-	– 11 –
468		-	(2) dispenses drugs, medical devices, medical appliances, or medical goods
469		-	for the treatment of a human disease or dysfunction; OR
	442	+	(2) a nonprofit health service plan; 12
470	443
471		-	(3) PROVIDES ANY OTHER C ARE, SERVICE, OR TREATMENT OF
472		-	DISEASE OR INJURY , THE CORRECTION OF DE FECTS, OR THE MAINTENANCE O F
473		-	PHYSICAL OR MENTAL W ELL–BEING OF INDIVIDUALS .
	444	+	(3) a health maintenance organization; 13
474	445
475		-	(l) (1) “Member” means a person entitled to health care benefits under a
476		-	policy, plan, or certificate issued or delivered in the State by a carrier.
	446	+	(4) a dental plan organization; 14
477	447
478		-	(2) “Member” includes:
	448	+	(5) a self–funded student health plan operated by an independent 15
	449	+	institution of higher education, as defined in § 10–101 of the Education Article, that 16
	450	+	provides health care to its students and their dependents; or 17
479	451
480		-	(i) a subscriber; and
	452	+	(6) except for a managed care organization as defined in Title 15, Subtitle 18
	453	+	1 of the Health – General Article, any other person that provides health benefit plans 19
	454	+	subject to regulation by the State. 20
481	455
482		-	(ii) unless preempted by federal law, a Medicare recipient.
	456	+	(d) “Complaint” means a protest filed with the Commissioner involving an 21
	457	+	adverse decision or grievance decision concerning the member. 22
483	458
484		-	(3) “Member” does not include a Medicaid recipient.
	459	+	(e) “Designee of the Commissioner” means any person to whom the Commissioner 23
	460	+	has delegated the authority to review and decide complaints filed under this subtitle, 24
	461	+	including an administrative law judge to whom the authority to conduct a hearing has been 25
	462	+	delegated for recommended or final decision. 26
485	463
486		-	(m) “Member’s representative” means an individual who has been authorized by
487		-	the member to file a grievance or a complaint on the member’s behalf.
	464	+	(f) “Grievance” means a protest filed by a member, a member’s representative, or 27
	465	+	a health care provider on behalf of a member with a carrier through the carrier’s internal 28
	466	+	grievance process regarding an adverse decision concerning the member. 29
488	467
489		-	(n) “Private review agent” has the meaning stated in § 15–10B–01 of this title.
	468	+	(g) “Grievance decision” means a final determination by a carrier that arises from 30
	469	+	a grievance filed with the carrier under its internal grievance process regarding an adverse 31
	470	+	decision concerning a member. 32 SENATE BILL 791 11
490	471
491		-	15–10A–02.
492	472
493		-	(a) Each carrier shall establish an internal grievance process for its members.
494	473
495		-	(b) (1) An internal grievance process shall meet the same requirements
496		-	established under Subtitle 10B of this title.
	474	+	(h) “Health Advocacy Unit” means the Health Education and Advocacy Unit in 1
	475	+	the Division of Consumer Protection of the Office of the Attorney General established under 2
	476	+	Title 13, Subtitle 4A of the Commercial Law Article. 3
497	477
498		-	(2) In addition to the requirements of Subtitle 10B of this title, an internal
499		-	grievance process established by a carrier under this section shall:
	478	+	(i) “Health benefit plan” has the meaning stated in § 2–112.2(a) of this article. 4
500	479
501		-	(i) include an expedited procedure for use in an emergency case for
502		-	purposes of rendering a grievance decision within 24 hours of the date a grievance is filed
503		-	with the carrier;
	480	+	(j) “Health care provider” means: 5
504	481
505		-	(ii) provide that a carrier render a final decision in writing on a
506		-	grievance within 30 working days after the date on which the grievance is filed unless:
	482	+	(1) an individual who is licensed under the Health Occupations Article to 6
	483	+	provide health care services in the ordinary course of business or practice of a profession 7
	484	+	and is a treating provider of the member; or 8
507	485
508		-	1. the grievance involves an emergency case under item (i) of
509		-	this paragraph;
	486	+	(2) a hospital, as defined in § 19–301 of the Health – General Article. 9
510	487
511		-	2. the member, the member’s representative, or a health care
512		-	provider filing a grievance on behalf of a member agrees in writing to an extension for a
513		-	period of no longer than 30 working days; or Ch. 848 2024 LAWS OF MARYLAND
	488	+	(k) “Health care service” means a health or medical care procedure or service 10
	489	+	rendered by a health care provider that: 11
514	490
515		-	– 12 –
	491	+	(1) provides testing, diagnosis, or treatment of a human disease or 12
	492	+	dysfunction; [or] 13
516	493
517		-	~~3. the grievance involves a retrospective denial under item~~
518		-	~~(iv)~~ of ~~this paragraph~~;
	494	+	(2) dispenses drugs, medical devices, medical appliances, or medical goods 14
	495	+	for the treatment of a human disease or dysfunction; OR 15
519	496
520		-	(iii) allow a grievance to be filed on behalf of a member by a health
521		-	care provider or the member’s representative;
	497	+	(3) PROVIDES ANY OTHER C ARE, SERVICE, OR TREATMENT OF 16
	498	+	DISEASE OR INJURY , THE CORRECTION OF DE FECTS, OR THE MAINTENANCE O F 17
	499	+	PHYSICAL OR MENTAL W ELL–BEING OF INDIVIDUALS . 18
522	500
523		-	(iv) provide that a carrier render a final decision in writing on a
524		-	grievance within 45 working days after the date on which the grievance is filed when the
525		-	grievance involves a retrospective denial; and
	501	+	(l) (1) “Member” means a person entitled to health care benefits under a 19
	502	+	policy, plan, or certificate issued or delivered in the State by a carrier. 20
526	503
527		-	(v) for a retrospective denial, allow a member, the member’s
528		-	representative, or a health care provider on behalf of a member to file a grievance for at
529		-	least 180 days after the member receives an adverse decision.
	504	+	(2) “Member” includes: 21
530	505
531		-	(3) For purposes of using the expedited procedure for an emergency case
532		-	that a carrier is required to include under paragraph (2)(i) of this subsection, the
533		-	[Commissioner shall define by regulation the standards required for a grievance to be
534		-	considered an emergency case] CARRIER SHALL INITIATE THE EXPEDITED PROCEDURE
535		-	FOR AN EMERGENCY CAS E IF THE MEMBER OR THE ME MBER’S REPRESENTATIVE
536		-	REQUESTS THE EXPEDIT ED REVIEW OR THE HEALTH CARE PROV IDER OR THE
537		-	MEMBER OR THE MEMBER ’S REPRESENTATIVE ATTESTS THAT:
	506	+	(i) a subscriber; and 22
538	507
539		-	(I) THE ADVERSE DECISION WAS RENDERED FOR HEALT H CARE
540		-	SERVICES THAT ARE PR OPOSED BUT HAVE NOT BEEN PROVIDED ; AND
	508	+	(ii) unless preempted by federal law, a Medicare recipient. 23
541	509
542		-	(II) THE SERVICES ARE NEC ESSARY TO TREAT A CO NDITION OR
543		-	ILLNESS THAT, WITHOUT IMMEDIATE ME DICAL ATTENTION , WOULD:
	510	+	(3) “Member” does not include a Medicaid recipient. 24
544	511
545		-	~~1. SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH O F THE~~
546		-	MEMBER OR THE MEMBER ’S ~~ABILITY TO REGAIN MAXIMUM FUNCTIONS ;~~
	512	+	(m) “Member’s representative” means an individual who has been authorized by 25
	513	+	the member to file a grievance or a complaint on the member’s behalf. 26
547	514
548		-	2. CAUSE THE MEMBER TO BE IN DANGER TO SELF OR
549		-	OTHERS; OR
	515	+	(n) “Private review agent” has the meaning stated in § 15–10B–01 of this title. 27
550	516
551		-	3. ~~CAUSE THE MEMBER TO CONTINUE USING~~
552		-	~~INTOXICATING SUBSTAN CES IN AN IMMINENTLY DANGEROUS MANNER .~~
	517	+	15–10A–02. 28
	518	+	12 SENATE BILL 791
553	519
554		-	(c) Except as provided in subsection (d) of this section, the carrier’s internal
555		-	grievance process shall be exhausted prior to filing a complaint with the Commissioner
556		-	under this subtitle.
557	520
558		-	(d) (1) (i) A member, the member’s representative, or a health care
559		-	provider filing a complaint on behalf of a member may file a complaint with the WES MOORE, Governor Ch. 848
	521	+	(a) Each carrier shall establish an internal grievance process for its members. 1
560	522
561		-	– 13 –
562		-	Commissioner without first filing a grievance with a carrier and receiving a final decision
563		-	on the grievance if:
	523	+	(b) (1) An internal grievance process shall meet the same requirements 2
	524	+	established under Subtitle 10B of this title. 3
564	525
565		-	1. the ~~carrier waives the requirement that the carrier’s~~
566		-	~~internal~~ grievance process ~~be exhausted before filing~~ a ~~complaint with the Commissioner;~~
	526	+	(2) In addition to the requirements of Subtitle 10B of this title, an internal 4
	527	+	grievance process established by a carrier under this section shall: 5
567	528
568		-	2. the carrier has failed to comply with any of the
569		-	requirements of the internal grievance process as described in this section; or
	529	+	(i) include an expedited procedure for use in an emergency case for 6
	530	+	purposes of rendering a grievance decision within 24 hours of the date a grievance is filed 7
	531	+	with the carrier; 8
570	532
571		-	3. the member, the member’s representative, or the health
572		-	care provider provides sufficient information and supporting documentation in the
573		-	complaint that demonstrates a compelling reason to do so.
	533	+	(ii) provide that a carrier render a final decision in writing on a 9
	534	+	grievance within 30 working days after the date on which the grievance is filed unless: 10
574	535
575		-	(ii) The Commissioner shall define by regulation the standards that
576		-	the Commissioner shall use to decide what demonstrates a compelling reason under
577		-	subparagraph (i) of this paragraph.
	536	+	1. the grievance involves an emergency case under item (i) of 11
	537	+	this paragraph; 12
578	538
579		-	(2) Subject to subsections (b)(2)(ii) and (h) of this section, a member, a
580		-	member’s representative, or a health care provider may file a complaint with the
581		-	Commissioner if the member, the member’s representative, or the health care provider does
582		-	not receive a grievance decision from the carrier on or before the 30th working day on which
583		-	the grievance is filed.
	539	+	2. the member, the member’s representative, or a health care 13
	540	+	provider filing a grievance on behalf of a member agrees in writing to an extension for a 14
	541	+	period of no longer than 30 working days; or 15
584	542
585		-	(3) Whenever the Commissioner receives a complaint under paragraph (1)
586		-	or (2) of this subsection, the Commissioner shall notify the carrier that is the subject of the
587		-	complaint within 5 working days after the date the complaint is filed with the
588		-	Commissioner.
	543	+	3. the grievance involves a retrospective denial under item 16
	544	+	(iv) of this paragraph; 17
589	545
590		-	(e) Each carrier shall:
	546	+	(iii) allow a grievance to be filed on behalf of a member by a health 18
	547	+	care provider or the member’s representative; 19
591	548
592		-	(1) file for review with the Commissioner and submit to the Health
593		-	Advocacy Unit a copy of its internal grievance process established under this subtitle; and
	549	+	(iv) provide that a carrier render a final decision in writing on a 20
	550	+	grievance within 45 working days after the date on which the grievance is filed when the 21
	551	+	grievance involves a retrospective denial; and 22
594	552
595		-	(2) file any revision to the internal grievance process with the
596		-	Commissioner and the Health Advocacy Unit at least 30 days before its intended use.
	553	+	(v) for a retrospective denial, allow a member, the member’s 23
	554	+	representative, or a health care provider on behalf of a member to file a grievance for at 24
	555	+	least 180 days after the member receives an adverse decision. 25
597	556
598		-	(f) (1) For nonemergency cases, when a carrier renders an adverse decision,
599		-	the carrier shall:
	557	+	(3) For purposes of using the expedited procedure for an emergency case 26
	558	+	that a carrier is required to include under paragraph (2)(i) of this subsection, the 27
	559	+	[Commissioner shall define by regulation the standards required for a grievance to be 28
	560	+	considered an emergency case] CARRIER SHALL INITIA TE THE EXPEDITED PRO CEDURE 29
	561	+	FOR AN EMERGENCY CAS E IF THE MEMBER OR THE ME MBER’S REPRESENTATIVE 30
	562	+	REQUESTS THE EXPEDIT ED REVIEW OR THE HEALTH CARE PROV IDER OR THE 31
	563	+	MEMBER OR THE MEMBER ’S REPRESENTATIVE ATTESTS THAT: 32
600	564
601		-	~~[(1)]~~ (I) ~~inform~~ the ~~member, the member’s representative,~~ ~~or the health~~
602		-	~~care provider acting on behalf of the member of the adverse decision:~~
	565	+	(I) THE ADVERSE DECISION WAS RENDERED FOR HEA LTH CARE 33
	566	+	SERVICES THAT ARE PR OPOSED BUT HAVE NOT BEEN PROVIDED ; AND 34 SENATE BILL 791 13
603	567
604		-	[(i)] 1. orally by telephone; or
605		-	Ch. 848 2024 LAWS OF MARYLAND
606	568
607		-	– 14 –
608		-	[(ii)] 2. with the affirmative consent of the member, the member’s
609		-	representative, or the health care provider acting on behalf of the member, by text,
610		-	facsimile, e–mail, an online portal, or other expedited means; and
611	569
612		-	[(2)] (II) send, within 5 working days after the adverse decision has been
613		-	made, a written notice to the member, the member’s representative, and a health care
614		-	provider acting on behalf of the member that:
	570	+	(II) THE SERVICES ARE NEC ESSARY TO TREAT A CO NDITION OR 1
	571	+	ILLNESS THAT, WITHOUT IMMEDIATE ME DICAL ATTENTION , WOULD: 2
615	572
616		-	[(i)] 1. states in detail in clear, understandable language the
617		-	specific factual bases for the carrier’s decision AND THE REASONING US ED TO
618		-	DETERMINE THAT THE H EALTH CARE SERVICE I S NOT MEDICALLY NECE SSARY AND
619		-	DID NOT MEET THE CAR RIER’S CRITERIA AND STAND ARDS USED IN CONDUCT ING
620		-	THE UTILIZATION REVI EW;
	573	+	1. SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH O F THE 3
	574	+	MEMBER OR THE MEMBER ’S ABILITY TO REGAIN MAXIMUM FUNCTIONS ; 4
621	575
622		-	[(ii)] 2. [references] PROVIDES the specific REFERENCE ,
623		-	LANGUAGE, OR REQUIREMENTS FROM THE criteria and standards, including ANY
624		-	interpretive guidelines, on which the decision was based, and may not solely use:
	576	+	2. CAUSE THE MEMBER TO BE IN DANGER TO SELF OR 5
	577	+	OTHERS; OR 6
625	578
626		-	A. generalized terms such as “experimental procedure not
627		-	covered”, “cosmetic procedure not covered”, “service included under another procedure”, or
628		-	“not medically necessary”; OR
	579	+	3. CAUSE THE MEMBER TO CONTINUE USING 7
	580	+	INTOXICATING SUBSTAN CES IN AN IMMINENTLY DANGEROUS MANNER . 8
629	581
630		-	B. LANGUAGE DIRECTING T HE MEMBER TO REVIEW THE
631		-	ADDITIONAL COVERAGE CRITERIA IN THE MEMBER ’S POLICY OR PLAN DOC UMENTS;
	582	+	(c) Except as provided in subsection (d) of this section, the carrier’s internal 9
	583	+	grievance process shall be exhausted prior to filing a complaint with the Commissioner 10
	584	+	under this subtitle. 11
632	585
633		-	[(iii)] 3. states the name, business address, and business telephone
634		-	number of:
	586	+	(d) (1) (i) A member, the member’s representative, or a health care 12
	587	+	provider filing a complaint on behalf of a member may file a complaint with the 13
	588	+	Commissioner without first filing a grievance with a carrier and receiving a final decision 14
	589	+	on the grievance if: 15
635	590
636		-	[1.] A. IF THE CARRIER IS A HEALTH MAINTENANCE
637		-	ORGANIZATION , the medical director or associate medical director, as appropriate, who
638		-	made the decision [if the carrier is a health maintenance organization]; or
	591	+	1. the carrier waives the requirement that the carrier’s 16
	592	+	internal grievance process be exhausted before filing a complaint with the Commissioner; 17
639	593
640		-	[2.] B. IF THE CARRIER IS NO T A HEALTH
641		-	MAINTENANCE ORGANIZA TION, the designated employee or representative of the carrier
642		-	who has responsibility for the carrier’s internal grievance process [if the carrier is not a
643		-	health maintenance organization] AND THE PHYSICIAN WH O IS REQUIRED TO MAK E
644		-	ALL ADVERSE DECISION S AS REQUIRED IN § 15–10B–07(A) OF THIS TITLE;
	594	+	2. the carrier has failed to comply with any of the 18
	595	+	requirements of the internal grievance process as described in this section; or 19
645	596
646		-	[(iv)] 4. gives written details of the carrier’s internal grievance
647		-	process and procedures under this subtitle; and
	597	+	3. the member, the member’s representative, or the health 20
	598	+	care provider provides sufficient information and supporting documentation in the 21
	599	+	complaint that demonstrates a compelling reason to do so. 22
648	600
649		-	[(v)] 5. includes the following information:
650		-	WES MOORE, Governor Ch. 848
	601	+	(ii) The Commissioner shall define by regulation the standards that 23
	602	+	the Commissioner shall use to decide what demonstrates a compelling reason under 24
	603	+	subparagraph (i) of this paragraph. 25
651	604
652		-	– 15 –
653		-	[1.] A. that the member, the member’s representative, or a
654		-	health care provider on behalf of the member has a right to file a complaint with the
655		-	Commissioner within 4 months after receipt of a carrier’s grievance decision;
	605	+	(2) Subject to subsections (b)(2)(ii) and (h) of this section, a member, a 26
	606	+	member’s representative, or a health care provider may file a complaint with the 27
	607	+	Commissioner if the member, the member’s representative, or the health care provider does 28
	608	+	not receive a grievance decision from the carrier on or before the 30th working day on which 29
	609	+	the grievance is filed. 30
656	610
657		-	~~[2.] B.~~ ~~that~~ a complaint ~~may be filed without first filing a~~
658		-	~~grievance if the member~~, the ~~member’s representative,~~ ~~or a health care provider filing a~~
659		-	~~grievance on behalf of~~ the ~~member can demonstrate a compelling reason to do so as~~
660		-	~~determined by the Commissioner;~~
	611	+	(3) Whenever the Commissioner receives a complaint under paragraph (1) 31
	612	+	or (2) of this subsection, the Commissioner shall notify the carrier that is the subject of the 32
	613	+	complaint within 5 working days after the date the complaint is filed with the 33
	614	+	Commissioner. 34 14 SENATE BILL 791
661	615
662		-	[3.] C. the Commissioner’s address, telephone number,
663		-	and facsimile number;
664	616
665		-	[4.] D. a statement that the Health Advocacy Unit is
666		-	available to assist the member or the member’s representative in both mediating and filing
667		-	a grievance under the carrier’s internal grievance process; and
668	617
669		-	[5.] E. the address, telephone number, facsimile number,
670		-	and electronic mail address of the Health Advocacy Unit.
	618	+	(e) Each carrier shall: 1
671	619
672		-	(2) THE BUSINESS TELEPHON E NUMBER INCLUDED IN THE NOTICE AS
673		-	REQUIRED UNDER PARAG RAPH (1)(II)3 OF THIS SUBSECTION M UST BE A DEDICATED
674		-	NUMBER FOR ADVERSE D ECISIONS AND MAY NOT BE THE GENERAL CUSTO MER CALL
675		-	NUMBER FOR THE CARRI ER.
	620	+	(1) file for review with the Commissioner and submit to the Health 2
	621	+	Advocacy Unit a copy of its internal grievance process established under this subtitle; and 3
676	622
677		-	(g) If within 5 working days after a member, the member’s representative, or a
678		-	health care provider, who has filed a grievance on behalf of a member, files a grievance
679		-	with the carrier, and if the carrier does not have sufficient information to complete its
680		-	internal grievance process, the carrier shall:
	623	+	(2) file any revision to the internal grievance process with the 4
	624	+	Commissioner and the Health Advocacy Unit at least 30 days before its intended use. 5
681	625
682		-	(1) ~~AFTER CONFIRMING THR OUGH~~ A ~~COMPLETE REVI EW OF ANY~~
683		-	~~INFORMATION ALREADY SUBMITTED BY~~ THE ~~HEA LTH CARE PROVIDER~~ :
	626	+	(f) (1) For nonemergency cases, when a carrier renders an adverse decision, 6
	627	+	the carrier shall: 7
684	628
685		-	(I) notify the member, the member’s representative, or the health
686		-	care provider that it cannot proceed with reviewing the grievance unless additional
687		-	information is provided;
	629	+	[(1)] (I) inform the member, the member’s representative, or the health 8
	630	+	care provider acting on behalf of the member of the adverse decision: 9
688	631
689		-	(II) REQUEST THE SPECIFIC INFORMATION , INCLUDING ANY
690		-	LAB OR DIAGNOSTIC TE ST OR OTHER MEDICAL INFORMATION THAT MUS T BE
691		-	SUBMITTED TO COMPLET E THE INTERNAL GRIEV ANCE PROCESS ; AND
	632	+	[(i)] 1. orally by telephone; or 10
692	633
693		-	(III) PROVIDE T HE SPECIFIC REFERENC E, LANGUAGE, OR
694		-	REQUIREMENTS FROM TH E CRITERIA AND STAND ARDS USED BY THE CAR RIER TO
695		-	SUPPORT THE NEED FOR THE ADDITIONAL INFOR MATION; and
696		-	Ch. 848 2024 LAWS OF MARYLAND
	634	+	[(ii)] 2. with the affirmative consent of the member, the member’s 11
	635	+	representative, or the health care provider acting on behalf of the member, by text, 12
	636	+	facsimile, e–mail, an online portal, or other expedited means; and 13
697	637
698		-	~~– 16 –~~
699		-	~~(2) assist~~ the member, the member’s representative, ~~or the~~ health care
700		-	provider ~~in gathering~~ the ~~necessary information without further delay.~~
	638	+	[(2)] (II) send, within 5 working days after the adverse decision has been 14
	639	+	made, a written notice to the member, the member’s representative, and a health care 15
	640	+	provider acting on behalf of the member that: 16
701	641
702		-	(h) A carrier may extend the 30–day or 45–day period required for making a final
703		-	grievance decision under subsection (b)(2)(ii) of this section with the written consent of the
704		-	member, the member’s representative, or the health care provider who filed the grievance
705		-	on behalf of the member.
	642	+	[(i)] 1. states in detail in clear, understandable language the 17
	643	+	specific factual bases for the carrier’s decision AND THE REASONING US ED TO 18
	644	+	DETERMINE THAT THE H EALTH CARE SERVICE I S NOT MEDICALLY NECE SSARY AND 19
	645	+	DID NOT MEET THE CAR RIER’S CRITERIA AND STANDARD S USED IN CONDUCTING 20
	646	+	THE UTILIZATION REVI EW; 21
706	647
707		-	(i) (1) For nonemergency cases, when a carrier renders a grievance decision,
708		-	the carrier shall:
	648	+	[(ii)] 2. [references] PROVIDES the specific REFERENCE , 22
	649	+	LANGUAGE, OR REQUIREMENTS FROM THE criteria and standards, including ANY 23
	650	+	interpretive guidelines, on which the decision was based, and may not solely use: 24
709	651
710		-	~~(i) document the grievance decision in writing after the carrier has~~
711		-	~~provided oral communication of the decision to the member~~, ~~the member’s representative~~,
712		-	or ~~the health care provider acting on behalf of the member; and~~
	652	+	A. generalized terms such as “experimental procedure not 25
	653	+	covered”, “cosmetic procedure not covered”, “service included under another procedure”, or 26
	654	+	“not medically necessary”; OR 27
713	655
714		-	(ii) send, within 5 working days after the grievance decision has been
715		-	made, a written notice to the member, the member’s representative, and a health care
716		-	provider acting on behalf of the member that:
	656	+	B. LANGUAGE DIRECTING T HE MEMBER TO REVIEW THE 28
	657	+	ADDITIONAL COVERAGE CRITERIA IN THE MEMB ER’S POLICY OR PLAN DOC UMENTS; 29
717	658
718		-	1. states in detail in clear, understandable language the
719		-	specific factual bases for the carrier’s decision AND THE REASONING US ED TO
720		-	DETERMINE THAT THE HEALTH C ARE SERVICE IS NOT M EDICALLY NECESSARY A ND
721		-	DID NOT MEET THE CAR RIER’S CRITERIA AND STAND ARDS USED IN CONDUCT ING
722		-	UTILIZATION REVIEW ;
	659	+	[(iii)] 3. states the name, business address, and business telephone 30
	660	+	number of: 31
	661	+	SENATE BILL 791 15
723	662
724		-	2. [references] PROVIDES the specific REFERENCE ,
725		-	LANGUAGE, OR REQUIREMENTS FROM THE criteria and standards, including ANY
726		-	interpretive guidelines USED BY THE CARRIER , on which the grievance decision was
727		-	based;
728	663
729		-	3. states the name, business address, and business telephone
730		-	number of:
	664	+	[1.] A. IF THE CARRIER IS A HEALTH MAINTENANCE 1
	665	+	ORGANIZATION , the medical director or associate medical director, as appropriate, who 2
	666	+	made the decision [if the carrier is a health maintenance organization]; or 3
731	667
732		-	A. IF THE CARRIER IS A HEALTH MAINTENANCE
733		-	ORGANIZATION , the medical director or associate medical director, as appropriate, who
734		-	made the grievance decision; or
	668	+	[2.] B. IF THE CARRIER IS NO T A HEALTH 4
	669	+	MAINTENANCE ORGANIZA TION, the designated employee or representative of the carrier 5
	670	+	who has responsibility for the carrier’s internal grievance process [if the carrier is not a 6
	671	+	health maintenance organization] AND THE PHYSICIAN WH O IS REQUIRED TO MAK E 7
	672	+	ALL ADVERSE DECISION S AS REQUIRED IN § 15–10B–07(A) OF THIS TITLE; 8
735	673
736		-	B. IF THE CARRIER IS NO T A HEALTH MAINTENAN CE
737		-	ORGANIZATION , the designated employee or representative of the carrier who has
738		-	responsibility for the carrier’s internal grievance process [if the carrier is not a health
739		-	maintenance organization] AND THE DESIGNATED E MPLOYEE OR REPRESENT ATIVE’S
740		-	TITLE AND CLINICAL S PECIALTY; and
	674	+	[(iv)] 4. gives written details of the carrier’s internal grievance 9
	675	+	process and procedures under this subtitle; and 10
741	676
742		-	4. includes the following information:
743		-	WES MOORE, Governor Ch. 848
	677	+	[(v)] 5. includes the following information: 11
744	678
745		-	– 17 –
746		-	A. that the member or the member’s representative has a
747		-	right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s
748		-	grievance decision;
	679	+	[1.] A. that the member, the member’s representative, or a 12
	680	+	health care provider on behalf of the member has a right to file a complaint with the 13
	681	+	Commissioner within 4 months after receipt of a carrier’s grievance decision; 14
749	682
750		-	B. the Commissioner’s address, telephone number, and
751		-	facsimile number;
	683	+	[2.] B. that a complaint may be filed without first filing a 15
	684	+	grievance if the member, the member’s representative, or a health care provider filing a 16
	685	+	grievance on behalf of the member can demonstrate a compelling reason to do so as 17
	686	+	determined by the Commissioner; 18
752	687
753		-	C. a statement that the Health Advocacy Unit is available to
754		-	assist the member or the member’s representative in filing a complaint with the
755		-	Commissioner; and
	688	+	[3.] C. the Commissioner’s address, telephone number, 19
	689	+	and facsimile number; 20
756	690
757		-	D. the address, telephone number, facsimile number, and
758		-	electronic mail address of the Health Advocacy Unit.
	691	+	[4.] D. a statement that the Health Advocacy Unit is 21
	692	+	available to assist the member or the member’s representative in both mediating and filing 22
	693	+	a grievance under the carrier’s internal grievance process; and 23
759	694
760		-	(2) THE BUSINESS TELEPHON E NUMBER INCLUDED IN THE NOTICE AS
761		-	REQUIRED UNDER PARAG RAPH (1)(II)3 OF THIS SUBSECTION M UST BE A DEDICATED
762		-	NUMBER FOR GRIEVANCE DECISIONS AND MAY NO T BE THE GENERAL CUSTOMER
763		-	CALL NUMBER FOR THE CARRIER.
	695	+	[5.] E. the address, telephone number, facsimile number, 24
	696	+	and electronic mail address of the Health Advocacy Unit. 25
764	697
765		-	[(2)] (3) [A] TO SATISFY THE REQUIR EMENTS OF THIS SUBSE CTION,
766		-	A carrier may not use solely in [a] THE WRITTEN notice sent under paragraph (1) of this
767		-	subsection:
	698	+	(2) THE BUSINESS TELEPHON E NUMBER INCLUDED IN THE NOTICE AS 26
	699	+	REQUIRED UNDER PARAG RAPH (1)(II)3 OF THIS SUBSECTION M UST BE A DEDICATED 27
	700	+	NUMBER FOR ADVERSE D ECISIONS AND MAY NOT BE THE GENERAL CUS TOMER CALL 28
	701	+	NUMBER FOR THE CARRI ER. 29
768	702
769		-	(I) generalized terms such as “experimental procedure not covered”,
770		-	“cosmetic procedure not covered”, “service included under another procedure”, or “not
771		-	medically necessary” [to satisfy the requirements of this subsection]; OR
	703	+	(g) If within 5 working days after a member, the member’s representative, or a 30
	704	+	health care provider, who has filed a grievance on behalf of a member, files a grievance 31
	705	+	with the carrier, and if the carrier does not have sufficient information to complete its 32
	706	+	internal grievance process, the carrier shall: 33
	707	+	16 SENATE BILL 791
772	708
773		-	(II) LANGUAGE DIRECTING T HE MEMBER TO REVIEW THE
774		-	ADDITIONAL COVERAGE CRITERIA IN THE MEMB ER’S POLICY OR PLAN DOC UMENTS.
775	709
776		-	(j) (1) For an emergency case under subsection (b)(2)(i) of this section, within
777		-	1 day after a decision has been orally communicated to the member, the member’s
778		-	representative, or the health care provider, the carrier shall send notice in writing of any
779		-	adverse decision or grievance decision to:
	710	+	(1) AFTER CONFIRMING THR OUGH A COMPLETE REVI EW OF ANY 1
	711	+	INFORMATION ALREADY SUBMITTED BY THE HEA LTH CARE PROVIDER : 2
780	712
781		-	(i) the member and the member’s representative, if any; and
	713	+	(I) notify the member, the member’s representative, or the health 3
	714	+	care provider that it cannot proceed with reviewing the grievance unless additional 4
	715	+	information is provided; 5
782	716
783		-	(ii) if the grievance was filed on behalf of the member under
784		-	subsection (b)(2)(iii) of this section, the health care provider.
	717	+	(II) REQUEST THE SPECIFIC INFORMATION , INCLUDING ANY 6
	718	+	LAB OR DIAGNOSTIC TE ST OR OTHER MEDICAL INFORMATION THAT MUS T BE 7
	719	+	SUBMITTED TO COMPLETE THE INTE RNAL GRIEVANCE PROCE SS; AND 8
785	720
786		-	(2) A notice required to be sent under paragraph (1) of this subsection shall
787		-	include the following:
	721	+	(III) PROVIDE THE SPECIFIC REFERENCE , LANGUAGE, OR 9
	722	+	REQUIREMENTS FROM TH E CRITERIA AND STAND ARDS USED BY THE CAR RIER TO 10
	723	+	SUPPORT THE NEED FOR THE ADDITIONAL INFOR MATION; and 11
788	724
789		-	(i) for an adverse decision, the information required under
790		-	subsection (f) of this section; and
791		-	Ch. 848 2024 LAWS OF MARYLAND
	725	+	(2) assist the member, the member’s representative, or the health care 12
	726	+	provider in gathering the necessary information without further delay. 13
792	727
793		-	– 18 –
794		-	(ii) for a grievance decision, the information required under
795		-	subsection (i) of this section.
	728	+	(h) A carrier may extend the 30–day or 45–day period required for making a final 14
	729	+	grievance decision under subsection (b)(2)(ii) of this section with the written consent of the 15
	730	+	member, the member’s representative, or the health care provider who filed the grievance 16
	731	+	on behalf of the member. 17
796	732
797		-	(k) (1) Each carrier shall include the information required by subsection
798		-	[(f)(2)(iii), (iv), and (v)] (F)(1)(II)3, 4, AND 5 of this section in the policy, plan, certificate,
799		-	enrollment materials, or other evidence of coverage that the carrier provides to a member
800		-	at the time of the member’s initial coverage or renewal of coverage.
	733	+	(i) (1) For nonemergency cases, when a carrier renders a grievance decision, 18
	734	+	the carrier shall: 19
801	735
802		-	(2) Each carrier shall include as part of the information required by
803		-	paragraph (1) of this subsection a statement indicating that, when filing a complaint with
804		-	the Commissioner, the member or the member’s representative will be required to
805		-	authorize the release of any medical records of the member that may be required to be
806		-	reviewed for the purpose of reaching a decision on the complaint.
	736	+	(i) document the grievance decision in writing after the carrier has 20
	737	+	provided oral communication of the decision to the member, the member’s representative, 21
	738	+	or the health care provider acting on behalf of the member; and 22
807	739
808		-	(l) ~~(1) Nothing in this subtitle prohibits a carrier from delegating its internal~~
809		-	~~grievance process~~ to ~~a private review agent that has~~ a ~~certificate issued under Subtitle 10B~~
810		-	~~of this title and is~~ acting on behalf of the ~~carrier.~~
	740	+	(ii) send, within 5 working days after the grievance decision has been 23
	741	+	made, a written notice to the member, the member’s representative, and a health care 24
	742	+	provider acting on behalf of the member that: 25
811	743
812		-	(2) If a carrier delegates its internal grievance process to a private review
813		-	agent, the carrier shall be:
	744	+	1. states in detail in clear, understandable language the 26
	745	+	specific factual bases for the carrier’s decision AND THE REASONING US ED TO 27
	746	+	DETERMINE THAT THE H EALTH CARE SERVICE I S NOT MEDICALLY NECE SSARY AND 28
	747	+	DID NOT MEET THE CAR RIER’S CRITERIA AND STAND ARDS USED IN CONDUCT ING 29
	748	+	UTILIZATION REVIEW ; 30
814	749
815		-	(i) bound by the grievance decision made by the private review
816		-	agent acting on behalf of the carrier; and
	750	+	2. [references] PROVIDES the specific REFERENCE, 31
	751	+	LANGUAGE, OR REQUIREMENTS FROM THE criteria and standards, including ANY 32
	752	+	interpretive guidelines USED BY THE CARRIER , on which the grievance decision was 33
	753	+	based; 34
	754	+	SENATE BILL 791 17
817	755
818		-	(ii) responsible for a violation of any provision of this subtitle
819		-	regardless of the delegation made by the carrier under paragraph (1) of this subsection.
820	756
821		-	15–10A–04.
	757	+	3. states the name, business address, and business telephone 1
	758	+	number of: 2
822	759
823		-	~~(c) (1) It~~ is a ~~violation of this subtitle for a carrier to fail to fulfill the carrier’s~~
824		-	~~obligations to provide~~ or ~~reimburse for health care services specified in the carrier’s policies~~
825		-	or ~~contracts with members.~~
	760	+	A. IF THE CARRIER IS A HEA LTH MAINTENANCE 3
	761	+	ORGANIZATION , the medical director or associate medical director, as appropriate, who 4
	762	+	made the grievance decision; or 5
826	763
827		-	(2) If, in rendering an adverse decision or grievance decision, a carrier fails
828		-	to fulfill the carrier’s obligations to provide or reimburse for health care services specified
829		-	in the carrier’s policies or contracts with members, the Commissioner may:
	764	+	B. IF THE CARRIER IS NO T A HEALTH MAINTENAN CE 6
	765	+	ORGANIZATION , the designated employee or representative of the carrier who has 7
	766	+	responsibility for the carrier’s internal grievance process [if the carrier is not a health 8
	767	+	maintenance organization] AND THE DESIGNATED E MPLOYEE OR REPRESENT ATIVE’S 9
	768	+	TITLE AND CLINICAL S PECIALTY; and 10
830	769
831		-	~~(i) issue an administrative order that requires~~ the ~~carrier to~~:
	770	+	4. includes the following information: 11
832	771
833		-	1. cease inappropriate conduct or practices by the carrier or
834		-	any of the personnel employed or associated with the carrier;
	772	+	A. that the member or the member’s representative has a 12
	773	+	right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s 13
	774	+	grievance decision; 14
835	775
836		-	2. fulfill the carrier’s contractual obligations;
	776	+	B. the Commissioner’s address, telephone number, and 15
	777	+	facsimile number; 16
837	778
838		-	3. provide a health care service or payment that has been
839		-	denied improperly; or WES MOORE, Governor Ch. 848
	779	+	C. a statement that the Health Advocacy Unit is available to 17
	780	+	assist the member or the member’s representative in filing a complaint with the 18
	781	+	Commissioner; and 19
840	782
841		-	– 19 –
	783	+	D. the address, telephone number, facsimile number, and 20
	784	+	electronic mail address of the Health Advocacy Unit. 21
842	785
843		-	4. take appropriate steps to restore the carrier’s ability to
844		-	provide a health care service or payment that is provided under a contract; or
	786	+	(2) THE BUSINESS TELEPHON E NUMBER INCLUDED IN THE NOTICE AS 22
	787	+	REQUIRED UNDER PARAG RAPH (1)(II)3 OF THIS SUBSECTION M UST BE A DEDICATED 23
	788	+	NUMBER FOR GRIEVANCE DECISIONS AND MAY NO T BE THE GENERAL CUS TOMER 24
	789	+	CALL NUMBER FOR THE CARRIER. 25
845	790
846		-	(ii) impose any penalty or fine or take any action as authorized:
	791	+	[(2)] (3) [A] TO SATISFY THE REQUIR EMENTS OF THIS SUBSE CTION, 26
	792	+	A carrier may not use solely in [a] THE WRITTEN notice sent under paragraph (1) of this 27
	793	+	subsection: 28
847	794
848		-	1. for an insurer, nonprofit health service plan, or dental
849		-	plan organization, under this article; or
	795	+	(I) generalized terms such as “experimental procedure not covered”, 29
	796	+	“cosmetic procedure not covered”, “service included under another procedure”, or “not 30
	797	+	medically necessary” [to satisfy the requirements of this subsection]; OR 31
850	798
851		-	2. for a health maintenance organization, under the Health
852		-	– General Article or under this article.
	799	+	(II) LANGUAGE DIRECTING T HE MEMBER TO REVIEW THE 32
	800	+	ADDITIONAL COVERAGE CRITERIA IN THE MEMB ER’S POLICY OR PLAN DOCUMENTS . 33
	801	+	18 SENATE BILL 791
853	802
854		-	(3) In addition to paragraph (1) of this subsection, it is a violation of this
855		-	subtitle, if the Commissioner, in consultation with an independent review organization,
856		-	medical expert, the Department, or other appropriate entity, determines that the criteria
857		-	and standards used by a health maintenance organization to conduct utilization review are
858		-	not[:
859	803
860		-	(i) objective;
	804	+	(j) (1) For an emergency case under subsection (b)(2)(i) of this section, within 1
	805	+	1 day after a decision has been orally communicated to the member, the member’s 2
	806	+	representative, or the health care provider, the carrier shall send notice in writing of any 3
	807	+	adverse decision or grievance decision to: 4
861	808
862		-	(ii) ~~clinically valid~~;
	809	+	(i) the member and the member’s representative, if any; and 5
863	810
864		-	(iii) compatible with established principles of health care; or
	811	+	(ii) if the grievance was filed on behalf of the member under 6
	812	+	subsection (b)(2)(iii) of this section, the health care provider. 7
865	813
866		-	(iv) ~~flexible enough~~ to ~~allow deviations from norms when justified on~~
867		-	~~a case by case basis] IN ACCORDANCE WITH § 15–10B–06 § 15–10B–05 OF THIS TITLE.~~
	814	+	(2) A notice required to be sent under paragraph (1) of this subsection shall 8
	815	+	include the following: 9
868	816
869		-	15–10A–06.
	817	+	(i) for an adverse decision, the information required under 10
	818	+	subsection (f) of this section; and 11
870	819
871		-	(a) ~~On [~~a ~~quarterly] AN ANNUAL basis~~, ~~each carrier shall submit to~~ the
872		-	~~Commissioner, on the form the Commissioner requires, a report that describes:~~
	820	+	(ii) for a grievance decision, the information required under 12
	821	+	subsection (i) of this section. 13
873	822
874		-	(1) the activities of the carrier under this subtitle, including:
	823	+	(k) (1) Each carrier shall include the information required by subsection 14
	824	+	[(f)(2)(iii), (iv), and (v)] (F)(1)(II)3, 4, AND 5 of this section in the policy, plan, certificate, 15
	825	+	enrollment materials, or other evidence of coverage that the carrier provides to a member 16
	826	+	at the time of the member’s initial coverage or renewal of coverage. 17
875	827
876		-	(i) the outcome of each grievance filed with the carrier;
	828	+	(2) Each carrier shall include as part of the information required by 18
	829	+	paragraph (1) of this subsection a statement indicating that, when filing a complaint with 19
	830	+	the Commissioner, the member or the member’s representative will be required to 20
	831	+	authorize the release of any medical records of the member that may be required to be 21
	832	+	reviewed for the purpose of reaching a decision on the complaint. 22
877	833
878		-	(ii) the number and outcomes of cases that were considered
879		-	emergency cases under § 15–10A–02(b)(2)(i) of this subtitle;
	834	+	(l) (1) Nothing in this subtitle prohibits a carrier from delegating its internal 23
	835	+	grievance process to a private review agent that has a certificate issued under Subtitle 10B 24
	836	+	of this title and is acting on behalf of the carrier. 25
880	837
881		-	(~~iii~~) ~~the time within which the~~ carrier ~~made~~ a ~~grievance decision on~~
882		-	~~each emergency case;~~
	838	+	(2) If a carrier delegates its internal grievance process to a private review 26
	839	+	agent, the carrier shall be: 27
883	840
884		-	(iv) the time within which the carrier made a grievance decision on
885		-	all other cases that were not considered emergency cases;
886		-	Ch. 848 2024 LAWS OF MARYLAND
	841	+	(i) bound by the grievance decision made by the private review 28
	842	+	agent acting on behalf of the carrier; and 29
887	843
888		-	– 20 –
889		-	(v) the number of grievances filed with the carrier that resulted from
890		-	an adverse decision involving length of stay for inpatient hospitalization as related to the
891		-	medical procedure involved; [and]
	844	+	(ii) responsible for a violation of any provision of this subtitle 30
	845	+	regardless of the delegation made by the carrier under paragraph (1) of this subsection. 31
892	846
893		-	(vi) the number of adverse decisions issued by the carrier under §
894		-	15–10A–02(f) of this subtitle, THE TYPE OF UTILIZAT ION REVIEW PROCESS U SED, IF
895		-	APPLICABLE, WHETHER THE ADVERSE D ECISION INVOLVED A P RIOR
896		-	AUTHORIZATION OR STE P THERAPY PROTOCOL , and the type of service at issue in the
897		-	adverse decisions; [and]
	847	+	15–10A–04. 32
	848	+	SENATE BILL 791 19
898	849
899		-	(VII) THE TIME WITHIN WHIC H THE CARRIER MADE T HE ADVERSE
900		-	DECISIONS UNDER EACH TYPE OF SERVICE AT I SSUE IN THE ADVERSE DECIS IONS;
901	850
902		-	(VIII) (VII) THE NUMBER OF ADVERS E DECISIONS OVERTURN ED
903		-	AFTER A RECONSIDERAT ION REQUEST UNDER § 15–10B–06 OF THIS TITLE; AND
	851	+	(c) (1) It is a violation of this subtitle for a carrier to fail to fulfill the carrier’s 1
	852	+	obligations to provide or reimburse for health care services specified in the carrier’s policies 2
	853	+	or contracts with members. 3
904	854
905		-	(IX) (VIII) THE NUMBER OF REQUES TS MADE AND GRANTED
906		-	UNDER § 15–831(C)(1) AND (2) OF THIS TITLE; AND
	855	+	(2) If, in rendering an adverse decision or grievance decision, a carrier fails 4
	856	+	to fulfill the carrier’s obligations to provide or reimburse for health care services specified 5
	857	+	in the carrier’s policies or contracts with members, the Commissioner may: 6
907	858
908		-	(2) the number and outcome of all other cases that are not subject to
909		-	activities of the carrier under this subtitle that resulted from an adverse decision involving
910		-	the length of stay for inpatient hospitalization as related to the medical procedure involved.
	859	+	(i) issue an administrative order that requires the carrier to: 7
911	860
912		-	(b) The Commissioner shall:
	861	+	1. cease inappropriate conduct or practices by the carrier or 8
	862	+	any of the personnel employed or associated with the carrier; 9
913	863
914		-	~~(1) compile an annual summary report based on~~ the ~~information provided:~~
	864	+	2. fulfill the carrier’s contractual obligations; 10
915	865
916		-	(i) under subsection (a) of this section; and
	866	+	3. provide a health care service or payment that has been 11
	867	+	denied improperly; or 12
917	868
918		-	~~(ii) by~~ the ~~Secretary under § 19–705.2(e) of the Health – General~~
919		-	~~Article~~; ~~[and]~~
	869	+	4. take appropriate steps to restore the carrier’s ability to 13
	870	+	provide a health care service or payment that is provided under a contract; or 14
920	871
921		-	(2) REPORT ANY VIOLATION S OR ACTIONS TAKEN U NDER §
922		-	15–10B–11 OF THIS TITLE; AND
	872	+	(ii) impose any penalty or fine or take any action as authorized: 15
923	873
924		-	~~[(2)] (3) provide copies of the summary report to the Governor and~~,
925		-	~~subject to § 2–1257 of the State Government~~ Article~~, to the General Assembly.~~
	874	+	1. for an insurer, nonprofit health service plan, or dental 16
	875	+	plan organization, under this article; or 17
926	876
927		-	15–10A–08.
	877	+	2. for a health maintenance organization, under the Health 18
	878	+	– General Article or under this article. 19
928	879
929		-	(a) ~~On or before November~~ 1, ~~1999, and each November 1 thereafter,~~ ~~the Health~~
930		-	~~Advocacy Unit shall publish~~ an ~~annual summary report and provide copies of the report to~~
931		-	~~the Governor and, subject to § 2–1257 of the State Government Article~~, the ~~General~~
932		-	~~Assembly.~~
933		-	~~WES MOORE, Governor Ch. 848~~
	880	+	(3) In addition to paragraph (1) of this subsection, it is a violation of this 20
	881	+	subtitle, if the Commissioner, in consultation with an independent review organization, 21
	882	+	medical expert, the Department, or other appropriate entity, determines that the criteria 22
	883	+	and standards used by a health maintenance organization to conduct utilization review are 23
	884	+	not[: 24
934	885
935		-	– 21 –
936		-	(b) (1) The annual summary report required under subsection (a) of this
937		-	section shall be on the grievances and complaints filed with or referred to a carrier, the
938		-	Commissioner, the Health Advocacy Unit, or any other federal or State government agency
939		-	or unit under this subtitle during the previous fiscal year.
	886	+	(i) objective; 25
940	887
941		-	(2) In consultation with the Commissioner and any affected State
942		-	government agency or unit, the Health Advocacy Unit shall:
	888	+	(ii) clinically valid; 26
943	889
944		-	(i) evaluate the effectiveness of the internal grievance process and
945		-	complaint process available to members; and
	890	+	(iii) compatible with established principles of health care; or 27
946	891
947		-	(ii) include in the annual summary report the results of the
948		-	evaluation and any proposed changes TO THE LAW that it considers necessary TO ENSURE
949		-	COMPLIANCE WITH THE PURPOSES OF THE LAW .
	892	+	(iv) flexible enough to allow deviations from norms when justified on 28
	893	+	a case by case basis] IN ACCORDANCE WITH § 15–10B–06 § 15–10B–05 OF THIS TITLE. 29
950	894
951		-	15–10B–01.
	895	+	15–10A–06. 30
	896	+	20 SENATE BILL 791
952	897
953		-	(a) In this subtitle the following words have the meanings indicated.
954	898
955		-	(b) ~~(1) “Adverse decision” means~~ a ~~utilization review determination made by a~~
956		-	~~private review agent~~ that ~~a proposed or delivered health care service~~:
	899	+	(a) On [a quarterly] AN ANNUAL basis, each carrier shall submit to the 1
	900	+	Commissioner, on the form the Commissioner requires, a report that describes: 2
957	901
958		-	(i) ~~is or was not medically necessary~~, ~~appropriate, or efficient; and~~
	902	+	(1) the activities of the carrier under this subtitle, including: 3
959	903
960		-	(ii) ~~may result in noncoverage~~ of the ~~health care service.~~
	904	+	(i) the outcome of each grievance filed with the carrier; 4
961	905
962		-	(2) “ADVERSE DECISION ” INCLUDES A UTILIZATI ON REVIEW
963		-	DETERMINATION BASED ON A PRIOR AUTHORIZA TION OR STEP THERAPY
964		-	REQUIREMENT .
	906	+	(ii) the number and outcomes of cases that were considered 5
	907	+	emergency cases under § 15–10A–02(b)(2)(i) of this subtitle; 6
965	908
966		-	~~[(2)]~~ (3) ~~“Adverse decision”~~ ~~does not include~~ a decision ~~concerning a~~
967		-	~~subscriber’s status as a member.~~
	909	+	(iii) the time within which the carrier made a grievance decision on 7
	910	+	each emergency case; 8
968	911
969		-	15–10B–02.
	912	+	(iv) the time within which the carrier made a grievance decision on 9
	913	+	all other cases that were not considered emergency cases; 10
970	914
971		-	The purpose of this subtitle is to:
	915	+	(v) the number of grievances filed with the carrier that resulted from 11
	916	+	an adverse decision involving length of stay for inpatient hospitalization as related to the 12
	917	+	medical procedure involved; [and] 13
972	918
973		-	(1) promote the delivery of quality health care in a cost effective manner
974		-	THAT ENSURES TIMELY ACCESS TO HEALTH CAR E SERVICES;
	919	+	(vi) the number of adverse decisions issued by the carrier under § 14
	920	+	15–10A–02(f) of this subtitle, THE TYPE OF UTILIZAT ION REVIEW PROCESS U SED, IF 15
	921	+	APPLICABLE, WHETHER THE ADVERSE DECISION INVOLVED A PRIOR 16
	922	+	AUTHORIZATION OR STEP THERAPY PROT OCOL, and the type of service at issue in the 17
	923	+	adverse decisions; [and] 18
975	924
976		-	(2) ~~foster greater coordination,~~ ~~COMMUNICATION , AND TRANSPARENCY~~
977		-	~~between payors,~~ ~~PATIENTS, and providers conducting utilization review activities~~;
	925	+	(VII) THE TIME WITHIN WHIC H THE CARRIER MADE T HE ADVERSE 19
	926	+	DECISIONS UNDER EACH TYPE OF SERVICE AT I SSUE IN THE ADVERSE DECISIONS; 20
978	927
979		-	(3) protect patients, business, and providers by ensuring that private
980		-	review agents are qualified to perform utilization review activities and to make informed
981		-	decisions on the appropriateness of medical care; and Ch. 848 2024 LAWS OF MARYLAND
	928	+	(VIII) (VII) THE NUMBER OF ADVERSE DECISIONS OV ERTURNED 21
	929	+	AFTER A RECONSIDERAT ION REQUEST UNDER § 15–10B–06 OF THIS TITLE; AND 22
982	930
983		-	– 22 –
	931	+	(IX) (VIII) THE NUMBER OF REQUES TS MADE AND GRANTED 23
	932	+	UNDER § 15–831(C)(1) AND (2) OF THIS TITLE; AND 24
984	933
985		-	(4) ensure that private review agents maintain the confidentiality of
986		-	medical records in accordance with applicable State and federal laws.
	934	+	(2) the number and outcome of all other cases that are not subject to 25
	935	+	activities of the carrier under this subtitle that resulted from an adverse decision involving 26
	936	+	the length of stay for inpatient hospitalization as related to the medical procedure involved. 27
987	937
988		-	~~15–10B–05.~~
	938	+	(b) The Commissioner shall: 28
989	939
990		-	(a) In conjunction with the application, the private review agent shall submit
991		-	information that the Commissioner requires including:
	940	+	(1) compile an annual summary report based on the information provided: 29
992	941
993		-	(1) a utilization review plan that includes:
	942	+	(i) under subsection (a) of this section; and 30
	943	+	SENATE BILL 791 21
994	944
995		-	(i) the specific criteria and standards to be used in conducting
996		-	utilization review of proposed or delivered health care services;
997	945
998		-	(ii) ~~those circumstances,~~ ~~if any,~~ under ~~which utilization review may~~
999		-	~~be delegated to a hospital utilization review program~~; and
	946	+	(ii) by the Secretary under § 19–705.2(e) of the Health – General 1
	947	+	Article; [and] 2
1000	948
1001		-	(~~iii~~) ~~if applicable,~~ any ~~provisions by which patients,~~ OR ~~physicians, or~~
1002		-	~~hospitals, OR OTHER HEALTH CARE PROVIDERS may seek reconsideration~~;
	949	+	(2) REPORT ANY VIOLATION S OR ACTIONS TAKEN U NDER § 3
	950	+	15–10B–11 OF THIS TITLE; AND 4
1003	951
1004		-	(2) ~~the type and qualifications~~ of the ~~personnel either employed or under~~
1005		-	~~contract~~ to ~~perform~~ the ~~utilization review;~~
	952	+	[(2)] (3) provide copies of the summary report to the Governor and, 5
	953	+	subject to § 2–1257 of the State Government Article, to the General Assembly. 6
1006	954
1007		-	(3) a copy of the private review agent’s internal grievance process if a
1008		-	carrier delegates its internal grievance process to the private review agent in accordance
1009		-	with § 15–10A–02(l) of this title;
	955	+	15–10A–08. 7
1010	956
1011		-	(4) the procedures and policies to ensure that a representative of the
1012		-	private review agent is reasonably accessible to patients and health care providers 7 days
1013		-	a week, 24 hours a day in this State;
	957	+	(a) On or before November 1, 1999, and each November 1 thereafter, the Health 8
	958	+	Advocacy Unit shall publish an annual summary report and provide copies of the report to 9
	959	+	the Governor and, subject to § 2–1257 of the State Government Article, the General 10
	960	+	Assembly. 11
1014	961
1015		-	(5) if applicable, the procedures and policies to ensure that a representative
1016		-	of the private review agent is accessible to health care providers to make all determinations
1017		-	on whether to authorize or certify an emergency inpatient admission, or an admission for
1018		-	residential crisis services as defined in § 15–840 of this title, for the treatment of a mental,
1019		-	emotional, or substance abuse disorder within 2 hours after receipt of the information
1020		-	necessary to make the determination;
	962	+	(b) (1) The annual summary report required under subsection (a) of this 12
	963	+	section shall be on the grievances and complaints filed with or referred to a carrier, the 13
	964	+	Commissioner, the Health Advocacy Unit, or any other federal or State government agency 14
	965	+	or unit under this subtitle during the previous fiscal year. 15
1021	966
1022		-	(6) the ~~policies~~ and ~~procedures to ensure that all applicable~~ State ~~and~~
1023		-	~~federal laws to protect~~ the ~~confidentiality of individual medical records are followed;~~
	967	+	(2) In consultation with the Commissioner and any affected State 16
	968	+	government agency or unit, the Health Advocacy Unit shall: 17
1024	969
1025		-	(7) ~~a copy~~ of the ~~materials designed to inform applicable patients~~ and
1026		-	~~providers of the requirements of the utilization review plan~~;
	970	+	(i) evaluate the effectiveness of the internal grievance process and 18
	971	+	complaint process available to members; and 19
1027	972
1028		-	(8) a list of the third party payors for which the private review agent is
1029		-	performing utilization review in this State; WES MOORE, Governor Ch. 848
	973	+	(ii) include in the annual summary report the results of the 20
	974	+	evaluation and any proposed changes TO THE LAW that it considers necessary TO ENSURE 21
	975	+	COMPLIANCE WITH THE PURPOSES OF THE LAW . 22
1030	976
1031		-	– 23 –
	977	+	15–10B–01. 23
1032	978
1033		-	(9) the policies and procedures to ensure that the private review agent has
1034		-	a formal program for the orientation and training of the personnel either employed or under
1035		-	contract to perform the utilization review;
	979	+	(a) In this subtitle the following words have the meanings indicated. 24
1036	980
1037		-	(10) a list of the persons involved in establishing the specific criteria and
1038		-	standards to be used in conducting utilization review, INCLUDING EACH PERSO N’S
1039		-	BOARD CERTIFICATION OR PRACTICE SPECIALT Y, LICENSURE CATEGORY , AND
1040		-	TITLE WITHIN THE PER SON’S ORGANIZATION ; and
	981	+	(b) (1) “Adverse decision” means a utilization review determination made by a 25
	982	+	private review agent that a proposed or delivered health care service: 26
1041	983
1042		-	(11) certification by the private review agent that the criteria and standards
1043		-	to be used in conducting utilization review are GENERALLY RECOGNIZED BY HEALTH
1044		-	CARE PROVIDERS PRACT ICING IN THE RELEVAN T CLINICAL SPECIALTI ES AND ARE:
	984	+	(i) is or was not medically necessary, appropriate, or efficient; and 27
1045	985
1046		-	(i) ~~objective;~~
	986	+	(ii) may result in noncoverage of the health care service. 28
1047	987
1048		-	(ii) clinically valid;
	988	+	(2) “ADVERSE DECISION ” INCLUDES A UTILIZATI ON REVIEW 29
	989	+	DETERMINATION BASED ON A PRIOR AUTHORIZA TION OR STEP THERAPY 30
	990	+	REQUIREMENT . 31
	991	+	22 SENATE BILL 791
1049	992
1050		-	[(iii) compatible with established principles of health care; and
1051	993
1052		-	(iv) ~~flexible enough to allow deviations from norms when justified on~~
1053		-	a ~~case by case basis;]~~
	994	+	[(2)] (3) “Adverse decision” does not include a decision concerning a 1
	995	+	subscriber’s status as a member. 2
1054	996
1055		-	(III) REFLECTED IN PUBLISHED PEER–REVIEWED SCIENTIFIC
1056		-	STUDIES AND MEDICAL LITERATURE;
	997	+	15–10B–02. 3
1057	998
1058		-	~~(IV) DEVELOPED BY~~ :
	999	+	The purpose of this subtitle is to: 4
1059	1000
1060		-	1. A NONPROFIT HEALTH C ARE PROVIDER
1061		-	PROFESSIONAL MEDICAL OR CLINICAL SPECIALT Y SOCIETY, INCLUDING THROUGH
1062		-	THE USE OF PATIENT P LACEMENT CRITERIA AN D CLINICAL PRACTICE GUIDELINES;
1063		-	OR
	1001	+	(1) promote the delivery of quality health care in a cost effective manner 5
	1002	+	THAT ENSURES TIMELY ACCESS TO HEALTH CAR E SERVICES; 6
1064	1003
1065		-	2. FOR CRITERIA NOT WIT HIN THE SCOPE OF A
1066		-	NONPROFIT HEALTH CARE PROVIDER PROFESSIONAL MEDICAL OR CLINICAL
1067		-	SPECIALTY SOCIETY , AN ORGANIZATION THAT WORKS DIRECTLY WITH HEALTH
1068		-	CARE PROVIDERS IN TH E SAME SPECIALTY FOR THE DESIGNATED CRITE RIA WHO
1069		-	ARE EMPLOYED OR ENGA GED WITHIN THE ORGAN IZATION OR OUTSIDE T HE
1070		-	ORGANIZATION TO DEVELO P THE CLINICAL CRITE RIA, IF THE ORGANIZATION :
	1004	+	(2) foster greater coordination, COMMUNICATION , AND TRANSPARENCY 7
	1005	+	between payors, PATIENTS, and providers conducting utilization review activities; 8
1071	1006
1072		-	~~A. DOES NOT RECEIVE DIR ECT PAYMENTS BASED O N THE~~
1073		-	~~OUTCOME OF THE UTILI ZATION~~ REVIEW ; AND
1074		-	~~Ch.~~ ~~848 2024 LAWS~~ OF ~~MARYLAND~~
	1007	+	(3) protect patients, business, and providers by ensuring that private 9
	1008	+	review agents are qualified to perform utilization review activities and to make informed 10
	1009	+	decisions on the appropriateness of medical care; and 11
1075	1010
1076		-	– 24 –
1077		-	B. DEMONSTRATES THAT IT S CLINICAL CRITERIA ARE
1078		-	CONSISTENT WITH CRIT ERIA AND STANDARDS G ENERALLY RECOGNIZED BY HE ALTH
1079		-	CARE PROVIDERS PRACT ICING IN THE RELEVAN T CLINICAL SPECIALTI ES;
	1011	+	(4) ensure that private review agents maintain the confidentiality of 12
	1012	+	medical records in accordance with applicable State and federal laws. 13
1080	1013
1081		-	~~(V) RECOMMENDED BY FEDER AL AGENCIES;~~
	1014	+	15–10B–05. 14
1082	1015
1083		-	(VI) ~~APPROVED BY~~ THE ~~FEDE~~ ~~RAL FOOD AND DRUG~~
1084		-	~~ADMINISTRATION AS PAR T OF DRUG LABELING ;~~
	1016	+	(a) In conjunction with the application, the private review agent shall submit 15
	1017	+	information that the Commissioner requires including: 16
1085	1018
1086		-	(VII) TAKING INTO ACCOUNT THE NEEDS OF ATYPICAL PA TIENT
1087		-	POPULATIONS AND DIAG NOSES, INCLUDING THE UNIQUE NEEDS OF CHILDREN AN D
1088		-	ADOLESCENTS ;
	1019	+	(1) a utilization review plan that includes: 17
1089	1020
1090		-	(VIII) SUFFICIENTLY FLEXIBL E TO ALLOW DEVIATION S FROM
1091		-	NORMS WHEN JUSTIFIED ON A CASE–BY–CASE BASIS, INCLUDING THE NEED T O USE
1092		-	AN OFF–LABEL PRESCRIPTION DRUG ;
	1021	+	(i) the specific criteria and standards to be used in conducting 18
	1022	+	utilization review of proposed or delivered health care services; 19
1093	1023
1094		-	(IX) ENSURING QUALITY OF CARE OF HEALTH CARE SERVICES;
	1024	+	(ii) those circumstances, if any, under which utilization review may 20
	1025	+	be delegated to a hospital utilization review program; and 21
1095	1026
1096		-	(X) ~~REVIEWED~~, ~~EVALUATED~~, ~~AND UPDATED AT LEAST~~
1097		-	~~ANNUALLY AND AS NECE SSARY TO REFLECT ANY CHANGES~~; ~~AND~~
	1027	+	(iii) if applicable, any provisions by which patients, OR physicians, or 22
	1028	+	hospitals, OR OTHER HEALTH CARE PROVIDERS may seek reconsideration; 23
1098	1029
1099		-	(XI) IN COMPLIANCE WITH A NY OTHER CRITERIA AN D
1100		-	STANDARDS REQUIRED F OR COVERAGE UNDER THIS TITLE, INCLUDING
1101		-	COMPLIANCE WITH § 15–802(D) OF THIS TITLE FOR TH E TREATMENT OF SUBST ANCE
1102		-	USE DISORDERS .
	1030	+	(2) the type and qualifications of the personnel either employed or under 24
	1031	+	contract to perform the utilization review; 25
1103	1032
1104		-	(b) [On the written request of any person or health care facility, the] THE private
1105		-	review agent shall [provide 1 copy of]:
	1033	+	(3) a copy of the private review agent’s internal grievance process if a 26
	1034	+	carrier delegates its internal grievance process to the private review agent in accordance 27
	1035	+	with § 15–10A–02(l) of this title; 28
1106	1036
1107		-	(1) POST ON ITS WEBSITE OR THE CARRIER ’S WEBSITE the specific
1108		-	criteria and standards to be used in conducting utilization review of proposed or delivered
1109		-	services and any subsequent revisions, modifications, or additions to the specific criteria
1110		-	and standards to be used in conducting utilization review of proposed or delivered services
1111		-	[to the person or health care facility making the request]; AND
	1037	+	(4) the procedures and policies to ensure that a representative of the 29
	1038	+	private review agent is reasonably accessible to patients and health care providers 7 days 30
	1039	+	a week, 24 hours a day in this State; 31 SENATE BILL 791 23
1112	1040
1113		-	(2) ON THE REQUEST OF A PERSON, INCLUDING A HEALTH C ARE
1114		-	FACILITY, PROVIDE A COPY OF TH E INFORMATION SPECIF IED UNDER ITEM (1) OF
1115		-	THIS SUBSECTION TO T HE PERSON MAKING THE REQUEST.
1116	1041
1117		-	(c) The private review agent may charge a reasonable fee for a HARD copy of the
1118		-	specific criteria and standards or any subsequent revisions, modifications, or additions to
1119		-	the specific criteria to any person or health care facility requesting a copy under subsection
1120		-	[(b)] (B)(2) of this section. WES MOORE, Governor Ch. 848
1121	1042
1122		-	– 25 –
	1043	+	(5) if applicable, the procedures and policies to ensure that a representative 1
	1044	+	of the private review agent is accessible to health care providers to make all determinations 2
	1045	+	on whether to authorize or certify an emergency inpatient admission, or an admission for 3
	1046	+	residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, 4
	1047	+	emotional, or substance abuse disorder within 2 hours after receipt of the information 5
	1048	+	necessary to make the determination; 6
1123	1049
1124		-	(d) ~~A private review agent shall advise~~ the ~~Commissioner, in writing,~~ ~~of a change~~
1125		-	~~in:~~
	1050	+	(6) the policies and procedures to ensure that all applicable State and 7
	1051	+	federal laws to protect the confidentiality of individual medical records are followed; 8
1126	1052
1127		-	(1) ~~ownership, medical director, or chief executive officer within 30 days~~ of
1128		-	~~the date~~ of the ~~change~~;
	1053	+	(7) a copy of the materials designed to inform applicable patients and 9
	1054	+	providers of the requirements of the utilization review plan; 10
1129	1055
1130		-	(2) the ~~name, address,~~ ~~or telephone number of~~ the private review agent
1131		-	~~within 30 days of the date of the change~~; or
	1056	+	(8) a list of the third party payors for which the private review agent is 11
	1057	+	performing utilization review in this State; 12
1132	1058
1133		-	(3) the private review agent’s scope of responsibility under a contract.
	1059	+	(9) the policies and procedures to ensure that the private review agent has 13
	1060	+	a formal program for the orientation and training of the personnel either employed or under 14
	1061	+	contract to perform the utilization review; 15
1134	1062
1135		-	15–10B–06.
	1063	+	(10) a list of the persons involved in establishing the specific criteria and 16
	1064	+	standards to be used in conducting utilization review, INCLUDING EACH PERSO N’S 17
	1065	+	BOARD CERTIFICATION OR PRACTICE SPECIALT Y, LICENSURE CATEGORY , AND 18
	1066	+	TITLE WITHIN THE PER SON’S ORGANIZATION ; and 19
1136	1067
1137		-	(a) (1) Except as OTHERWISE provided in [paragraph (4) of] this subsection,
1138		-	a private review agent shall:
	1068	+	(11) certification by the private review agent that the criteria and standards 20
	1069	+	to be used in conducting utilization review are GENERALLY RECOGNIZED BY HEALTH 21
	1070	+	CARE PROVIDERS PRACT ICING IN THE RELEVAN T CLINICAL SPECIALTI ES AND ARE: 22
1139	1071
1140		-	(i) make all initial determinations on whether to authorize or certify
1141		-	a nonemergency course of treatment OR HEALTH CARE SERVI CE, INCLUDING
1142		-	PHARMACEUTICAL SERVICES NOT SUBMITTED ELECTR ONICALLY, for a patient within
1143		-	2 working days after receipt of the information necessary to make the determination;
	1072	+	(i) objective; 23
1144	1073
1145		-	(ii) make all determinations on whether to authorize or certify an
1146		-	extended stay in a health care facility or additional health care services within 1 working
1147		-	day after receipt of the information necessary to make the determination; [and]
	1074	+	(ii) clinically valid; 24
1148	1075
1149		-	(III) MAKE ALL DETERMINATI ONS TO AUTHORIZE OR CERTIFY A
1150		-	REQUEST FOR ADDITION AL VISITS OR DAYS OF CARE SUBMITT ED AS PART OF AN
1151		-	EXISTING COURSE OF T REATMENT OR TREATMEN T PLAN WITHIN 1 WORKING DAY
1152		-	AFTER RECEIPT OF THE INFORMATION NECESSAR Y TO MAKE THE DETERM INATION;
1153		-	AND
	1076	+	[(iii) compatible with established principles of health care; and 25
1154	1077
1155		-	~~[(iii)]~~ (IV) ~~promptly notify the health care provider of the~~
1156		-	~~determination.~~
	1078	+	(iv) flexible enough to allow deviations from norms when justified on 26
	1079	+	a case by case basis;] 27
1157	1080
1158		-	(2) [If within 3 calendar days after] AFTER receipt of the initial request
1159		-	for health care services AND CONFIRMING THROU GH A COMPLETE REVIEW OF
1160		-	INFORMATION ALREADY SUBMITTED BY THE HEA LTH CARE PROVIDER , IF the private
1161		-	review agent DETERMINES THAT THE PRIVATE REVIEW AGEN T does not have sufficient
1162		-	information to make a determination, the private review agent shall PROMPTLY, BUT NOT
1163		-	LATER THAN 3 CALENDAR DAYS AFTER RECEIPT OF THE INITI AL REQUEST, inform
1164		-	the health care provider that additional information must be provided BY SPECIFYING:
1165		-	Ch. 848 2024 LAWS OF MARYLAND
	1081	+	(III) REFLECTED IN PUBLISHED PEER–REVIEWED SCIENTIFIC 28
	1082	+	STUDIES AND MEDICAL LITERATURE; 29
1166	1083
1167		-	– 26 –
1168		-	(I) THE INFORMATION , INCLUDING ANY LAB OR DIAGNOSTIC
1169		-	TEST OR OTHER MEDICA L INFORMATION , THAT MUST BE SUBMITT ED TO COMPLETE
1170		-	THE REQUEST ; AND
	1084	+	(IV) DEVELOPED BY : 30
1171	1085
1172		-	~~(II) THE CRITERIA AND STA NDARDS TO SUPPORT TH E NEED FOR~~
1173		-	~~ADDITIONAL INFORMATI ON.~~
	1086	+	1. A NONPROFIT HEALTH C ARE PROVIDER 31
	1087	+	PROFESSIONAL MEDICAL OR CLINICAL SPECIALT Y SOCIETY, INCLUDING THROUGH 32 24 SENATE BILL 791
1174	1088
1175		-	[(3)] (B) If a private review agent requires prior authorization for an
1176		-	emergency inpatient admission, or an admission for residential crisis services as defined in
1177		-	§ 15–840 of this title, for the treatment of a mental, emotional, or substance abuse disorder,
1178		-	the private review agent shall:
1179	1089
1180		-	[(i)] (1) make all determinations on whether to authorize or certify
1181		-	an inpatient admission, or an admission for residential crisis services as defined in §
1182		-	15–840 of this title, within 2 hours after receipt of the information necessary to make the
1183		-	determination; [and]
	1090	+	THE USE OF PATIENT P LACEMENT CRITERIA AN D CLINICAL PRACTICE GUIDELINES; 1
	1091	+	OR 2
1184	1092
1185		-	(2) IF ADDITIONAL INFORM ATION IS NEEDED , PROMPTLY REQUEST
1186		-	THE SPECIFIC INFORMA TION NEEDED, INCLUDING ANY LAB OR DIAGNOSTIC TEST OR
1187		-	OTHER MEDICAL INFORM ATION; AND
	1093	+	2. FOR CRITERIA NOT WIT HIN THE SCOPE OF A 3
	1094	+	NONPROFIT HEALTH CAR E PROVIDER PROFESSIO NAL MEDICAL OR CLINI CAL 4
	1095	+	SPECIALTY SOCIETY , AN ORGANIZATION THAT WORKS DIRECTLY WITH HEALTH 5
	1096	+	CARE PROVIDERS IN TH E SAME SPECIALTY FOR THE DESIGNATED CRITE RIA WHO 6
	1097	+	ARE EMPLOYED OR ENGA GED WITHIN THE ORGAN IZATION OR OUTSIDE T HE 7
	1098	+	ORGANIZATION TO DEVE LOP THE CLINICAL CRI TERIA, IF THE ORGANIZATION: 8
1188	1099
1189		-	~~[(ii)] (3) promptly notify~~ the ~~health care provider of the~~
1190		-	~~determination.~~
	1100	+	A. DOES NOT RECEIVE DIR ECT PAYMENTS BASED O N THE 9
	1101	+	OUTCOME OF THE UTILI ZATION REVIEW ; AND 10
1191	1102
1192		-	[(4)] (C) (1) For a step therapy exception request submitted
1193		-	electronically in accordance with a process established under § 15–142(f) of this title or a
1194		-	prior authorization request submitted electronically for pharmaceutical services, a private
1195		-	review agent shall make a determination:
	1103	+	B. DEMONSTRATES THAT IT S CLINICAL CRITERIA ARE 11
	1104	+	CONSISTENT WITH CRIT ERIA AND STANDARDS G ENERALLY RECOGNIZED BY HEALTH 12
	1105	+	CARE PROVIDERS PRACT ICING IN THE RELEVANT CLINICA L SPECIALTIES; 13
1196	1106
1197		-	(i) ~~in real time if:~~
	1107	+	(V) RECOMMENDED BY FEDER AL AGENCIES; 14
1198	1108
1199		-	~~1. no additional information is needed~~ by the ~~private review~~
1200		-	~~agent to process the request~~; ~~and~~
	1109	+	(VI) APPROVED BY THE FEDE RAL FOOD AND DRUG 15
	1110	+	ADMINISTRATION AS PAR T OF DRUG LABELING ; 16
1201	1111
1202		-	2. the request meets the private review agent’s criteria for
1203		-	approval; or
	1112	+	(VII) TAKING INTO ACCOUNT THE NEEDS OF ATYPICA L PATIENT 17
	1113	+	POPULATIONS AND DIAG NOSES, INCLUDING THE UNIQUE NEED S OF CHILDREN AND 18
	1114	+	ADOLESCENTS ; 19
1204	1115
1205		-	(ii) ~~if a request is not approved IN REAL TIME under item (i) of this~~
1206		-	~~paragraph~~, ~~within 1 [business] WORKING day after~~ the ~~private review agent receives all of~~
1207		-	~~the information necessary to make the determination.~~
	1116	+	(VIII) SUFFICIENTLY FLEXIBL E TO ALLOW DEVIATION S FROM 20
	1117	+	NORMS WHEN JUSTIFIED ON A CASE–BY–CASE BASIS, INCLUDING THE NEED T O USE 21
	1118	+	AN OFF–LABEL PRESCRIPTION D RUG; 22
1208	1119
1209		-	(2) IF ADDITIONAL INFORMA TION IS NEEDED TO MA KE A
1210		-	DETERMINATION AFTER CONFIRMING THROUGH A COMPLETE REVIEW OF T HE
1211		-	INFORMATION ALREADY SUBMITTED BY THE HEA LTH CARE PROVIDER , THE PRIVATE WES MOORE, Governor Ch. 848
	1120	+	(IX) ENSURING QUALITY OF CARE OF HEALTH CARE SERVICES ; 23
1212	1121
1213		-	– 27 –
1214		-	REVIEW AGENT SHALL R EQUEST THE INFORMATI ON PROMPTLY , BUT NOT LATER
1215		-	THAN 3 CALENDAR DAYS AFTER R ECEIPT OF THE INITIA L REQUEST, BY SPECIFYING:
	1122	+	(X) REVIEWED, EVALUATED, AND UPDATED AT LEAST 24
	1123	+	ANNUALLY AND AS NECE SSARY TO REFLECT ANY CHANGES; AND 25
1216	1124
1217		-	(I) THE INFORMATION , INCLUDING ANY LAB OR DIAGNOSTIC
1218		-	TEST OR OTHER MEDICA L INFORMATION , THAT MUST BE SUBMITT ED TO COMPLETE
1219		-	THE REQUEST ; AND
	1125	+	(XI) IN COMPLIANCE WITH A NY OTHER CRITERIA AN D 26
	1126	+	STANDARDS REQUIRED F OR COVERAGE UNDER TH IS TITLE, INCLUDING 27
	1127	+	COMPLIANCE WITH § 15–802(D) OF THIS TITLE FOR TH E TREATMENT OF SUBST ANCE 28
	1128	+	USE DISORDERS . 29
1220	1129
1221		-	(II) THE CRITERIA AND STA NDARDS TO SUPPORT THE NEED FOR
1222		-	THE ADDITIONAL INFOR MATION.
	1130	+	(b) [On the written request of any person or health care facility, the] THE private 30
	1131	+	review agent shall [provide 1 copy of]: 31
	1132	+	SENATE BILL 791 25
1223	1133
1224		-	(D) (1) (I) A EXCEPT AS PROVIDED IN SUBSECTIONS (G) AND (H) OF
1225		-	THIS SECTION, A PRIVATE REVIEW AGENT SHALL MAKE INITIAL D ETERMINATIONS
1226		-	ON WHETHER TO AUTHOR IZE OR CERTIFY AN EM ERGENCY COURSE OF TR EATMENT
1227		-	OR HEALTH CARE SERVICE FOR A M EMBER WITHIN 24 HOURS AFTER THE INIT IAL
1228		-	REQUEST AFTER RECEIP T OF THE INFORMATION NECESSARY TO MAKE TH E
1229		-	DETERMINATION .
1230	1134
1231		-	(II) IF THE PRIVATE REVIEW AGENT DETERMINES THA T
1232		-	ADDITIONAL INFORMATI ON IS NEEDED AFTER C ONFIRMING THROUGH A COMPLETE
1233		-	REVIEW OF THE INFORM ATION ALREADY SUBMIT TED BY THE HEALTH CA RE
1234		-	PROVIDER, THE PRIVATE REVIEW A GENT SHALL:
	1135	+	(1) POST ON ITS WEBSITE OR THE CARRIER ’S WEBSITE the specific 1
	1136	+	criteria and standards to be used in conducting utilization review of proposed or delivered 2
	1137	+	services and any subsequent revisions, modifications, or additions to the specific criteria 3
	1138	+	and standards to be used in conducting utilization review of proposed or delivered services 4
	1139	+	[to the person or health care facility making the request]; AND 5
1235	1140
1236		-	~~1. PROMPTLY~~ REQUEST ~~THE SPECIFIC INFORMATION~~
1237		-	~~NEEDED~~, ~~INCLUDING ANY LAB OR DIAGNOSTIC TEST OR O THER MEDICAL~~
1238		-	~~INFORMATION ; AND~~
	1141	+	(2) ON THE REQUEST OF A PERSON, INCLUDING A HEALTH C ARE 6
	1142	+	FACILITY, PROVIDE A COPY OF TH E INFORMATION SPECIF IED UNDER ITEM (1) OF 7
	1143	+	THIS SUBSECTION TO T HE PERSON MAKING THE REQUEST . 8
1239	1144
1240		-	~~2. PROMPTLY,~~ ~~BUT NOT LATER THAN 2 HOURS AFTER~~
1241		-	~~RECEIPT OF THE INFOR MATION~~, ~~NOTIFY THE HEALTH CA RE PROVIDER OF AN~~
1242		-	~~AUTHORIZATION~~ OR ~~CER TIFICATION DETERMINA TION WHEN MADE BY TH E PRIVATE~~
1243		-	~~REVIEW AGENT~~ .
	1145	+	(c) The private review agent may charge a reasonable fee for a HARD copy of the 9
	1146	+	specific criteria and standards or any subsequent revisions, modifications, or additions to 10
	1147	+	the specific criteria to any person or health care facility requesting a copy under subsection 11
	1148	+	[(b)] (B)(2) of this section. 12
1244	1149
1245		-	(2) A PRIVATE REVIEW AGENT SHALL INITIATE THE E XPEDITED
1246		-	PROCEDURE FOR AN EMERGENCY CASE IF THE PATIENT OR THE P ATIENT’S
1247		-	REPRESENTATIVE REQUE STS OR IF THE HEALTH CARE PROV IDER ATTESTS THAT
1248		-	THE SERVICES ARE NEC ESSARY TO TREAT A CO NDITION OR ILLNESS T HAT, WITHOUT
1249		-	IMMEDIATE MEDICAL AT TENTION, WOULD:
	1150	+	(d) A private review agent shall advise the Commissioner, in writing, of a change 13
	1151	+	in: 14
1250	1152
1251		-	(I) ~~SERIOUSLY JEOPARDIZE THE LIFE~~ OR ~~HEALTH O F THE~~
1252		-	~~MEMBER OR~~ THE ~~MEMBER ’S ABILITY TO REGAIN MAXIMUM FUNCTIONS~~ ;
	1153	+	(1) ownership, medical director, or chief executive officer within 30 days of 15
	1154	+	the date of the change; 16
1253	1155
1254		-	(II) CAUSE THE MEMBER TO BE IN DANGER TO SELF OR OTHERS;
1255		-	OR
1256		-	Ch. 848 2024 LAWS OF MARYLAND
	1156	+	(2) the name, address, or telephone number of the private review agent 17
	1157	+	within 30 days of the date of the change; or 18
1257	1158
1258		-	– 28 –
1259		-	(III) CAUSE THE MEMBER TO CONTINUE USING INTOX ICATING
1260		-	SUBSTANCES IN AN IMM INENTLY DANGEROUS MA NNER.
	1159	+	(3) the private review agent’s scope of responsibility under a contract. 19
1261	1160
1262		-	(E) IF A PRIVATE REVIEW A GENT FAILS TO MAKE A DETERMINATION WITHIN
1263		-	THE TIME LIMITS REQU IRED UNDER THIS SECT ION, THE REQUEST SHALL BE
1264		-	DEEMED APPROVED .
	1161	+	15–10B–06. 20
1265	1162
1266		-	[(b)] (F) (1) If an initial determination is made by a private review agent not
1267		-	to authorize or certify a health care service and the health care provider believes the
1268		-	determination warrants an immediate reconsideration, a private review agent [may]
1269		-	SHALL provide the health care provider the opportunity to speak with the physician that
1270		-	rendered the determination, by telephone on an expedited basis, within a period of time not
1271		-	to exceed 24 hours of the health care provider seeking the reconsideration.
	1163	+	(a) (1) Except as OTHERWISE provided in [paragraph (4) of] this subsection, 21
	1164	+	a private review agent shall: 22
1272	1165
1273		-	(2) IF THE PHYSICIAN IS U NABLE TO IMMEDIATELY SPEAK WITH THE
1274		-	HEALTH CARE PROVIDER SEEKING THE RECONSID ERATION, THE PHYSICIAN SHALL
1275		-	PROVIDE THE HEALTH C ARE PROVIDER WITH TH E FOLLOWING CONTACT
1276		-	INFORMATION FOR THE HEALTH CARE PROVIDER TO USE TO CONTACT TH E
1277		-	PHYSICIAN:
	1166	+	(i) make all initial determinations on whether to authorize or certify 23
	1167	+	a nonemergency course of treatment OR HEALTH CARE SERVI CE, INCLUDING 24
	1168	+	PHARMACEUTICAL SERVI CES NOT SUBMITTED EL ECTRONICALLY, for a patient within 25
	1169	+	2 working days after receipt of the information necessary to make the determination; 26
1278	1170
1279		-	(I) A DIRECT TELEPHONE N UMBER THAT IS NOT TH E GENERAL
1280		-	CUSTOMER CALL NUMBER ; OR
	1171	+	(ii) make all determinations on whether to authorize or certify an 27
	1172	+	extended stay in a health care facility or additional health care services within 1 working 28
	1173	+	day after receipt of the information necessary to make the determination; [and] 29
1281	1174
1282		-	(II) A MONITORED E –MAIL ADDRESS THAT IS DEDICATED TO
1283		-	COMMUNICATION RELATE D TO UTILIZATION REV IEW.
	1175	+	(III) MAKE ALL DETERMINATI ONS TO AUTHORIZE OR CERTIFY A 30
	1176	+	REQUEST FOR ADDITION AL VISITS OR DAYS OF CARE SUBMITTED AS PA RT OF AN 31
	1177	+	EXISTING COURSE OF TREATMENT OR TREATME NT PLAN WITHIN 1 WORKING DAY 32
	1178	+	AFTER RECEIPT OF THE INFORMATION NECESSAR Y TO MAKE THE DETERM INATION; 33
	1179	+	AND 34 26 SENATE BILL 791
1284	1180
1285		-	[(c)] (G) For emergency inpatient admissions, a private review agent may not
1286		-	render an adverse decision solely because the hospital did not notify the private review
1287		-	agent of the emergency admission within 24 hours or other prescribed period of time after
1288		-	that admission if the patient’s medical condition prevented the hospital from determining:
1289	1181
1290		-	(1) the patient’s insurance status; and
1291	1182
1292		-	(2) ~~if applicable,~~ the ~~private review agent’s emergency admission~~
1293		-	~~notification requirements~~.
	1183	+	[(iii)] (IV) promptly notify the health care provider of the 1
	1184	+	determination. 2
1294	1185
1295		-	[(d)] (H) (1) Subject to paragraph (2) of this subsection, a private review
1296		-	agent may not render an adverse decision as to an admission of a patient during the first
1297		-	24 hours after admission when:
	1186	+	(2) [If within 3 calendar days after] AFTER receipt of the initial request 3
	1187	+	for health care services AND CONFIRMING THROU GH A COMPLETE REVIEW OF 4
	1188	+	INFORMATION ALREADY SUBMITTED BY THE HEA LTH CARE PROVIDER , IF the private 5
	1189	+	review agent DETERMINES THAT THE PRIVATE REVIEW AGENT does not have sufficient 6
	1190	+	information to make a determination, the private review agent shall PROMPTLY, BUT NOT 7
	1191	+	LATER THAN 3 CALENDAR DAYS AFTER RECEIPT OF THE INITI AL REQUEST, inform 8
	1192	+	the health care provider that additional information must be provided BY SPECIFYING: 9
1298	1193
1299		-	(i) the ~~admission is based on a determination that the patient is in~~
1300		-	~~imminent danger~~ to ~~self or others;~~
1301		-	~~WES MOORE, Governor Ch. 848~~
	1194	+	(I) THE INFORMATIO N, INCLUDING ANY LAB OR DIAGNOSTIC 10
	1195	+	TEST OR OTHER MEDICA L INFORMATION , THAT MUST BE SUBMITT ED TO COMPLETE 11
	1196	+	THE REQUEST ; AND 12
1302	1197
1303		-	– 29 –
1304		-	(ii) the determination has been made by the patient’s physician or
1305		-	psychologist in conjunction with a member of the medical staff of the facility who has
1306		-	privileges to make the admission; and
	1198	+	(II) THE CRITERIA AND STA NDARDS TO SUPPORT TH E NEED FOR 13
	1199	+	ADDITIONAL INFORMATI ON. 14
1307	1200
1308		-	(iii) the hospital immediately notifies the private review agent of:
	1201	+	[(3)] (B) If a private review agent requires prior authorization for an 15
	1202	+	emergency inpatient admission, or an admission for residential crisis services as defined in 16
	1203	+	§ 15–840 of this title, for the treatment of a mental, emotional, or substance abuse disorder, 17
	1204	+	the private review agent shall: 18
1309	1205
1310		-	1. the admission of the patient; and
	1206	+	[(i)] (1) make all determinations on whether to authorize or certify 19
	1207	+	an inpatient admission, or an admission for residential crisis services as defined in § 20
	1208	+	15–840 of this title, within 2 hours after receipt of the information necessary to make the 21
	1209	+	determination; [and] 22
1311	1210
1312		-	2. the reasons for the admission.
	1211	+	(2) IF ADDITIONAL INFORM ATION IS NEEDED , PROMPTLY REQUEST 23
	1212	+	THE SPECIFIC INFORMA TION NEEDED, INCLUDING ANY LAB OR DIAGNOSTIC TEST OR 24
	1213	+	OTHER MEDICAL INFORM ATION; AND 25
1313	1214
1314		-	(2) A private review agent may not render an adverse decision as to an
1315		-	admission of a patient to a hospital for up to 72 hours, as determined to be medically
1316		-	necessary by the patient’s treating physician, when:
	1215	+	[(ii)] (3) promptly notify the health care provider of the 26
	1216	+	determination. 27
1317	1217
1318		-	(i) the admission is an involuntary admission under §§ 10–615 and
1319		-	10–617(a) of the Health – General Article; and
	1218	+	[(4)] (C) (1) For a step therapy exception request submitted 28
	1219	+	electronically in accordance with a process established under § 15–142(f) of this title or a 29
	1220	+	prior authorization request submitted electronically for pharmaceutical services, a private 30
	1221	+	review agent shall make a determination: 31
1320	1222
1321		-	(ii) ~~the hospital immediately notifies the private review agent of~~:
	1223	+	(i) in real time if: 32
1322	1224
1323		-	1. the admission of the patient; and
	1225	+	1. no additional information is needed by the private review 33
	1226	+	agent to process the request; and 34 SENATE BILL 791 27
1324	1227
1325		-	2. the reasons for the admission.
1326	1228
1327		-	[(e)] (I) (1) A private review agent that requires a health care provider to
1328		-	submit a treatment plan in order for the private review agent to conduct utilization review
1329		-	of proposed or delivered services for the treatment of a mental illness, emotional disorder,
1330		-	or a substance abuse disorder:
1331	1229
1332		-	(i) shall accept:
	1230	+	2. the request meets the private review agent’s criteria for 1
	1231	+	approval; or 2
1333	1232
1334		-	~~1. the uniform treatment plan form adopted by the~~
1335		-	~~Commissioner under § 15–10B–03(d)~~ of ~~this subtitle as a properly submitted treatment~~
1336		-	~~plan form;~~ or
	1233	+	(ii) if a request is not approved IN REAL TIME under item (i) of this 3
	1234	+	paragraph, within 1 [business] WORKING day after the private review agent receives all of 4
	1235	+	the information necessary to make the determination. 5
1337	1236
1338		-	2. if a service was provided in another state, a treatment plan
1339		-	form mandated by the state in which the service was provided; and
	1237	+	(2) IF ADDITIONAL INFORMA TION IS NEEDED TO MA KE A 6
	1238	+	DETERMIN ATION AFTER CONFIRMI NG THROUGH A COMPLET E REVIEW OF THE 7
	1239	+	INFORMATION ALREADY SUBMITTED BY THE HEA LTH CARE PROVIDER , THE PRIVATE 8
	1240	+	REVIEW AGENT SHALL R EQUEST THE INFORMATI ON PROMPTLY , BUT NOT LATER 9
	1241	+	THAN 3 CALENDAR DAYS AFTER RECEIPT OF THE INITI AL REQUEST, BY SPECIFYING: 10
1340	1242
1341		-	(ii) may not impose any requirement to:
	1243	+	(I) THE INFORMATION , INCLUDING ANY LAB OR DIAGNOSTIC 11
	1244	+	TEST OR OTHER MEDICA L INFORMATION , THAT MUST BE SUBMITT ED TO COMPLETE 12
	1245	+	THE REQUEST ; AND 13
1342	1246
1343		-	1. modify the uniform treatment plan form or its content; or
	1247	+	(II) THE CRITERIA AND STA NDARDS TO SUPPORT TH E NEED FOR 14
	1248	+	THE ADDITIONAL INFOR MATION. 15
1344	1249
1345		-	2. submit additional treatment plan forms.
	1250	+	(D) (1) (I) A EXCEPT AS PROVIDED IN SUBSECTIONS (G) AND (H) OF 16
	1251	+	THIS SECTION, A PRIVATE REVIEW AGENT SHALL MAKE INITIAL D ETERMINATIONS 17
	1252	+	ON WHETHER TO AUTHOR IZE OR CERTIFY AN EM ERGENCY COURSE OF TR EATMENT 18
	1253	+	OR HEALTH CARE SERVI CE FOR A MEMBER WITH IN 24 HOURS AFTER THE INITIAL 19
	1254	+	REQUEST AFTER RECEIP T OF THE INFORMATION NECESSARY TO MAKE TH E 20
	1255	+	DETERMINATION . 21
1346	1256
1347		-	(2) A uniform treatment plan form submitted under the provisions of this
1348		-	subsection:
1349		-	Ch. 848 2024 LAWS OF MARYLAND
	1257	+	(II) IF THE PRIVATE REVIEW AGENT DETERMINES THA T 22
	1258	+	ADDITIONAL INFORMATI ON IS NEEDED AFTER C ONFIRMING THROUGH A COMPLETE 23
	1259	+	REVIEW OF THE INFORM ATION ALREADY SUBMIT TED BY T HE HEALTH CARE 24
	1260	+	PROVIDER, THE PRIVATE REVIEW A GENT SHALL: 25
1350	1261
1351		-	– 30 –
1352		-	(i) shall be properly completed by the health care provider; and
	1262	+	1. PROMPTLY REQUEST THE SPECIFIC INFORMATION 26
	1263	+	NEEDED, INCLUDING ANY LAB OR DIAGNOSTIC TEST OR O THER MEDICAL 27
	1264	+	INFORMATION ; AND 28
1353	1265
1354		-	(ii) may be submitted by electronic transfer.
	1266	+	2. PROMPTLY, BUT NOT LATER THAN 2 HOURS AFTER 29
	1267	+	RECEIPT OF THE INFORMATION , NOTIFY THE HEALTH CA RE PROVIDER OF AN 30
	1268	+	AUTHORIZATION OR CER TIFICATION DETERMINA TION WHEN MADE BY TH E PRIVATE 31
	1269	+	REVIEW AGENT . 32
1355	1270
1356		-	15–10B–07.
	1271	+	(2) A PRIVATE REVIEW AGENT SHALL INITIATE THE E XPEDITED 33
	1272	+	PROCEDURE FOR AN EME RGENCY CASE IF THE PATIENT OR THE P ATIENT’S 34 28 SENATE BILL 791
1357	1273
1358		-	(a) (1) Except as provided in paragraphs (2) and (3) of this subsection, all
1359		-	adverse decisions shall be made by a LICENSED physician, or a panel of other appropriate
1360		-	health care service reviewers with at least one physician on the panel, who is:
1361	1274
1362		-	(I) board certified or eligible in the same specialty as the treatment
1363		-	under review; AND
	1275	+	REPRESENTATIVE REQUE STS OR IF THE HEALTH CARE PROV IDER ATTESTS THAT 1
	1276	+	THE SERVICES ARE NEC ESSARY TO TREAT A CO NDITION OR ILLNESS T HAT, WITHOUT 2
	1277	+	IMMEDIATE MEDICAL AT TENTION, WOULD: 3
1364	1278
1365		-	(II) ~~KNOWLEDGEABLE ABOUT~~ THE ~~REQUESTED~~ HEALTH ~~CARE~~
1366		-	~~SERVICE~~ OR ~~TREATMENT THROUGH ACTUAL CLINI CAL EXPERIENCE .~~
	1279	+	(I) SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH O F THE 4
	1280	+	MEMBER OR THE MEMBER ’S ABILITY TO REGAIN MA XIMUM FUNCTIONS ; 5
1367	1281
1368		-	(2) When the health care service under review is a mental health or
1369		-	substance abuse service, the adverse decision shall be made by a LICENSED physician, or
1370		-	a panel of other appropriate health care service reviewers with at least one LICENSED
1371		-	physician, selected by the private review agent who:
	1282	+	(II) CAUSE THE MEMBER TO BE IN DANGER TO SELF OR OTHERS; 6
	1283	+	OR 7
1372	1284
1373		-	(i) ~~is board certified or eligible in~~ the ~~same specialty as the~~
1374		-	~~treatment under review;~~ or
	1285	+	(III) CAUSE THE MEMBER TO CONTINUE USING INTOX ICATING 8
	1286	+	SUBSTANCES IN AN IMM INENTLY DANGEROUS MA NNER. 9
1375	1287
1376		-	(ii) is actively practicing or has demonstrated expertise in the
1377		-	substance abuse or mental health service or treatment under review.
	1288	+	(E) IF A PRIVATE REVIEW A GENT FAILS TO MAKE A DETERMINATION WITHIN 10
	1289	+	THE TIME LIMITS REQU IRED UNDER THIS SECT ION, THE REQUEST SHALL BE 11
	1290	+	DEEMED APPROVED . 12
1378	1291
1379		-	(3) When the health care service under review is a dental service, the
1380		-	adverse decision shall be made by a licensed dentist, or a panel of other appropriate health
1381		-	care service reviewers with at least one licensed dentist on the panel WHO IS
1382		-	KNOWLEDGEABLE ABOUT THE REQUESTED HEALTH CARE SERVICE OR TREA TMENT
1383		-	THROUGH ACTUAL CLINI CAL EXPERIENCE .
	1292	+	[(b)] (F) (1) If an initial determination is made by a private review agent not 13
	1293	+	to authorize or certify a health care service and the health care provider believes the 14
	1294	+	determination warrants an immediate reconsideration, a private review agent [may] 15
	1295	+	SHALL provide the health care provider the opportunity to speak with the physician that 16
	1296	+	rendered the determination, by telephone on an expedited basis, within a period of time not 17
	1297	+	to exceed 24 hours of the health care provider seeking the reconsideration. 18
1384	1298
1385		-	(b) All adverse decisions shall be made by a physician or a panel of other
1386		-	appropriate health care service reviewers who are not compensated by the private review
1387		-	agent in a manner that violates § 19–705.1 of the Health – General Article or that deters
1388		-	the delivery of medically appropriate care.
	1299	+	(2) IF THE PHYSICIAN IS UNABLE TO IMM EDIATELY SPEAK WITH THE 19
	1300	+	HEALTH CARE PROVIDER SEEKING THE RECONSID ERATION, THE PHYSICIAN SHALL 20
	1301	+	PROVIDE THE HEALTH C ARE PROVIDER WITH TH E FOLLOWING CONTACT 21
	1302	+	INFORMATION FOR THE HEALTH CARE PROVIDER TO USE TO CONTACT TH E 22
	1303	+	PHYSICIAN: 23
1389	1304
1390		-	(c) Except as provided in subsection (d) of this section, if a course of treatment
1391		-	has been preauthorized or approved for a patient, a private review agent may not
1392		-	retrospectively render an adverse decision regarding the preauthorized or approved
1393		-	services delivered to that patient.
	1305	+	(I) A DIRECT TELEPHONE N UMBER THAT IS NOT TH E GENERAL 24
	1306	+	CUSTOMER CALL NUMBER ; OR 25
1394	1307
1395		-	(d) A ~~private review agent may retrospectively render an adverse decision~~
1396		-	~~regarding preauthorized or approved services delivered~~ to ~~a patient if: WES MOORE, Governor Ch~~. ~~848~~
	1308	+	(II) A MONITORED E –MAIL ADDRESS THAT IS DEDICATED TO 26
	1309	+	COMMUNICATION RELATE D TO UTILIZATION REV IEW. 27
1397	1310
1398		-	– 31 –
	1311	+	[(c)] (G) For emergency inpatient admissions, a private review agent may not 28
	1312	+	render an adverse decision solely because the hospital did not notify the private review 29
	1313	+	agent of the emergency admission within 24 hours or other prescribed period of time after 30
	1314	+	that admission if the patient’s medical condition prevented the hospital from determining: 31
1399	1315
1400		-	(1) the information submitted to the private review agent regarding the
1401		-	services to be delivered to the patient was fraudulent or intentionally misrepresentative;
	1316	+	(1) the patient’s insurance status; and 32
1402	1317
1403		-	(2) critical information requested by the private review agent regarding
1404		-	services to be delivered to the patient was omitted such that the private review agent’s
1405		-	determination would have been different had the agent known the critical information; or
	1318	+	(2) if applicable, the private review agent’s emergency admission 33
	1319	+	notification requirements. 34 SENATE BILL 791 29
1406	1320
1407		-	(3) the planned course of treatment for the patient that was approved by
1408		-	the private review agent was not substantially followed by the provider.
1409	1321
1410		-	(e) If a course of treatment has been preauthorized or approved for a patient, a
1411		-	private review agent may not revise or modify the specific criteria or standards used for the
1412		-	utilization review to make an adverse decision regarding the services delivered to that
1413		-	patient.
1414	1322
1415		-	15–10B–09.1.
	1323	+	[(d)] (H) (1) Subject to paragraph (2) of this subsection, a private review 1
	1324	+	agent may not render an adverse decision as to an admission of a patient during the first 2
	1325	+	24 hours after admission when: 3
1416	1326
1417		-	A grievance decision shall be made based on the professional judgment of:
	1327	+	(i) the admission is based on a determination that the patient is in 4
	1328	+	imminent danger to self or others; 5
1418	1329
1419		-	(1) (i) a LICENSED physician who is board certified or eligible in the
1420		-	same specialty as the treatment under review AND KNOWLEDGEABLE AB OUT THE
1421		-	REQUESTED HEALTH CAR E SERVICE OR TREATME NT THROUGH ACTUAL CL INICAL
1422		-	EXPERIENCE ; or
	1330	+	(ii) the determination has been made by the patient’s physician or 6
	1331	+	psychologist in conjunction with a member of the medical staff of the facility who has 7
	1332	+	privileges to make the admission; and 8
1423	1333
1424		-	(ii) a panel of other appropriate health care service reviewers with
1425		-	at least one LICENSED physician on the panel who is board certified or eligible in the same
1426		-	specialty as the treatment under review AND KNOWLEDGEABLE AB OUT THE
1427		-	REQUESTED HEALTH CAR E SERVICE OR TREATME NT THROUGH ACTUAL CL INICAL
1428		-	EXPERIENCE ;
	1334	+	(iii) the hospital immediately notifies the private review agent of: 9
1429	1335
1430		-	(2) when the grievance decision involves a dental service, a licensed
1431		-	dentist, or a panel of appropriate health care service reviewers with at least one dentist on
1432		-	the panel who is a licensed dentist, who shall consult with a dentist who is board certified
1433		-	or eligible in the same specialty as the service under review AND KNOWLEDGEABLE
1434		-	ABOUT THE REQUESTED HEALTH CARE SERVICE OR TREATMENT THROUGH ACTUAL
1435		-	CLINICAL EXPERIENCE ; or
	1336	+	1. the admission of the patient; and 10
1436	1337
1437		-	(3) when the grievance decision involves a mental health or substance
1438		-	abuse service:
	1338	+	2. the reasons for the admission. 11
1439	1339
1440		-	(i) a licensed physician who:
	1340	+	(2) A private review agent may not render an adverse decision as to an 12
	1341	+	admission of a patient to a hospital for up to 72 hours, as determined to be medically 13
	1342	+	necessary by the patient’s treating physician, when: 14
1441	1343
1442		-	1. is board certified or eligible in the same specialty as the
1443		-	treatment under review; or
1444		-	Ch. 848 2024 LAWS OF MARYLAND
	1344	+	(i) the admission is an involuntary admission under §§ 10–615 and 15
	1345	+	10–617(a) of the Health – General Article; and 16
1445	1346
1446		-	– 32 –
1447		-	2. is actively practicing or has demonstrated expertise in the
1448		-	substance abuse or mental health service or treatment under review; or
	1347	+	(ii) the hospital immediately notifies the private review agent of: 17
1449	1348
1450		-	(ii) a panel of other appropriate health care service reviewers with
1451		-	at least one LICENSED physician, selected by the private review agent who:
	1349	+	1. the admission of the patient; and 18
1452	1350
1453		-	1. is board certified or eligible in the same specialty as the
1454		-	treatment under review; or
	1351	+	2. the reasons for the admission. 19
1455	1352
1456		-	2. is actively practicing or has demonstrated expertise in the
1457		-	substance abuse or mental health service or treatment under review.
	1353	+	[(e)] (I) (1) A private review agent that requires a health care provider to 20
	1354	+	submit a treatment plan in order for the private review agent to conduct utilization review 21
	1355	+	of proposed or delivered services for the treatment of a mental illness, emotional disorder, 22
	1356	+	or a substance abuse disorder: 23
1458	1357
1459		-	~~SECTION 2.~~ ~~AND BE IT FURTHER ENACTED, That~~:
	1358	+	(i) shall accept: 24
1460	1359
1461		-	(a) The Maryland Health Care Commission and the Maryland Insurance
1462		-	Administration, in consultation with health care practitioners and payors of health care
1463		-	services, jointly shall conduct a study on the development of standards for the
1464		-	implementation of payor programs to modify prior authorization requirements for
1465		-	prescription drugs, medical care, and other health care services based on health care
1466		-	practitioner–specific criteria.
	1360	+	1. the uniform treatment plan form adopted by the 25
	1361	+	Commissioner under § 15–10B–03(d) of this subtitle as a properly submitted treatment 26
	1362	+	plan form; or 27
1467	1363
1468		-	(b) The study conducted under subsection (a) of this section shall include, through
1469		-	an examination of literature review and legislatively or voluntarily established programs
1470		-	that have been implemented or are being considered in other states, an analysis of:
	1364	+	2. if a service was provided in another state, a treatment plan 28
	1365	+	form mandated by the state in which the service was provided; and 29
1471	1366
1472		-	(1) ~~adjustments~~ to ~~payor prior authorization requirements based on a~~
1473		-	~~health care practitioner’s:~~
	1367	+	(ii) may not impose any requirement to: 30
	1368	+	30 SENATE BILL 791
1474	1369
1475		-	(i) prior approval rates;
1476	1370
1477		-	~~(ii) ordering and prescribing patterns~~; ~~and~~
	1371	+	1. modify the uniform treatment plan form or its content; or 1
1478	1372
1479		-	(iii) participation in a payor’s two–sided incentive arrangement or a
1480		-	capitation program; and
	1373	+	2. submit additional treatment plan forms. 2
1481	1374
1482		-	(2) ~~any other information or metrics necessary to implement~~ the ~~payor~~
1483		-	~~programs.~~
	1375	+	(2) A uniform treatment plan form submitted under the provisions of this 3
	1376	+	subsection: 4
1484	1377
1485		-	(c) On or before December 1, 2024, the Maryland Health Care Commission and
1486		-	the Maryland Insurance Administration jointly shall submit a report to the General
1487		-	Assembly, in accordance with § 2–1257 of the State Government Article, with the findings
1488		-	and recommendations from the study, including recommendations for legislative initiatives
1489		-	necessary for the establishment of payor programs modifying prior authorization
1490		-	requirements based on health care practitioner–specific criteria.
	1378	+	(i) shall be properly completed by the health care provider; and 5
1491	1379
1492		-	~~SECTION 3. AND~~ BE ~~IT FURTHER ENACTED,~~ ~~That: WES MOORE, Governor Ch~~. ~~848~~
	1380	+	(ii) may be submitted by electronic transfer. 6
1493	1381
1494		-	– ~~33 –~~
	1382	+	15–10B–07. 7
1495	1383
1496		-	(a) ~~The Maryland Health Care Commission~~ and ~~the Maryland Insurance~~
1497		-	~~Administration jointly~~ shall ~~establish~~ a ~~workgroup to~~, ~~in consultation with the Maryland~~
1498		-	~~Insurance Administration~~, ~~shall~~:
	1384	+	(a) (1) Except as provided in paragraphs (2) and (3) of this subsection, all 8
	1385	+	adverse decisions shall be made by a LICENSED physician, or a panel of other appropriate 9
	1386	+	health care service reviewers with at least one physician on the panel, who is: 10
1499	1387
1500		-	(1) assess monitor the progress toward implementing the requirements in
1501		-	§ 19–108.5 of the Health – General Article, as enacted by Section 1 of this Act, including
1502		-	monitoring any federal or State developments relating to the requirements; and
	1388	+	(I) board certified or eligible in the same specialty as the treatment 11
	1389	+	under review; AND 12
1503	1390
1504		-	(2) review issues or recommendations from other states that are
1505		-	implementing a real–time benefit requirement, including establishing a link at the point of
1506		-	prescribing for any available coupons.
	1391	+	(II) KNOWLEDGEABLE ABOUT THE REQUESTED HEALTH CARE 13
	1392	+	SERVICE OR TREATMENT THROUGH ACTUAL CLINI CAL EXPERIENCE . 14
1507	1393
1508		-	(b) On or before December 1, 2025, the Maryland Health Care Commission and
1509		-	the Maryland Insurance Administration jointly shall submit a report to shall inform the
1510		-	General Assembly, in accordance with § 2–1257 of the State Government Article, with of
1511		-	any findings and recommendations from the workgroup relating to the implementation of
1512		-	§ 19–108.5 of the Health – General Article, as enacted by Section 1 of this Act.
	1394	+	(2) When the health care service under review is a mental health or 15
	1395	+	substance abuse service, the adverse decision shall be made by a LICENSED physician, or 16
	1396	+	a panel of other appropriate health care service reviewers with at least one LICENSED 17
	1397	+	physician, selected by the private review agent who: 18
1513	1398
1514		-	~~SECTION 4.~~ ~~AND BE IT FURTHER ENACTED,~~ ~~That Section 1 of this Act shall take~~
1515		-	~~effect January 1,~~ ~~2025.~~
	1399	+	(i) is board certified or eligible in the same specialty as the 19
	1400	+	treatment under review; or 20
1516	1401
1517		-	~~SECTION 5.~~ ~~AND BE IT FURTHER ENACTED,~~ ~~That, except as provided~~ in ~~Section~~
1518		-	~~4 of this Act,~~ ~~this Act shall take effect July 1, 2024~~.
	1402	+	(ii) is actively practicing or has demonstrated expertise in the 21
	1403	+	substance abuse or mental health service or treatment under review. 22
1519	1404
1520		-	Approved by the Governor, May 16, 2024.
	1405	+	(3) When the health care service under review is a dental service, the 23
	1406	+	adverse decision shall be made by a licensed dentist, or a panel of other appropriate health 24
	1407	+	care service reviewers with at least one licensed dentist on the panel WHO IS 25
	1408	+	KNOWLEDGEABLE ABOU T THE REQUESTED HEAL TH CARE SERVICE OR T REATMENT 26
	1409	+	THROUGH ACTUAL CLINI CAL EXPERIENCE . 27
	1410	+
	1411	+	(b) All adverse decisions shall be made by a physician or a panel of other 28
	1412	+	appropriate health care service reviewers who are not compensated by the private review 29
	1413	+	agent in a manner that violates § 19–705.1 of the Health – General Article or that deters 30
	1414	+	the delivery of medically appropriate care. 31
	1415	+	SENATE BILL 791 31
	1416	+
	1417	+
	1418	+	(c) Except as provided in subsection (d) of this section, if a course of treatment 1
	1419	+	has been preauthorized or approved for a patient, a private review agent may not 2
	1420	+	retrospectively render an adverse decision regarding the preauthorized or approved 3
	1421	+	services delivered to that patient. 4
	1422	+
	1423	+	(d) A private review agent may retrospectively render an adverse decision 5
	1424	+	regarding preauthorized or approved services delivered to a patient if: 6
	1425	+
	1426	+	(1) the information submitted to the private review agent regarding the 7
	1427	+	services to be delivered to the patient was fraudulent or intentionally misrepresentative; 8
	1428	+
	1429	+	(2) critical information requested by the private review agent regarding 9
	1430	+	services to be delivered to the patient was omitted such that the private review agent’s 10
	1431	+	determination would have been different had the agent known the critical information; or 11
	1432	+
	1433	+	(3) the planned course of treatment for the patient that was approved by 12
	1434	+	the private review agent was not substantially followed by the provider. 13
	1435	+
	1436	+	(e) If a course of treatment has been preauthorized or approved for a patient, a 14
	1437	+	private review agent may not revise or modify the specific criteria or standards used for the 15
	1438	+	utilization review to make an adverse decision regarding the services delivered to that 16
	1439	+	patient. 17
	1440	+
	1441	+	15–10B–09.1. 18
	1442	+
	1443	+	A grievance decision shall be made based on the professional judgment of: 19
	1444	+
	1445	+	(1) (i) a LICENSED physician who is board certified or eligible in the 20
	1446	+	same specialty as the treatment under review AND KNOWLEDGEABLE AB OUT THE 21
	1447	+	REQUESTED HEALTH CAR E SERVICE OR TREATME NT THROUGH ACTUAL CL INICAL 22
	1448	+	EXPERIENCE ; or 23
	1449	+
	1450	+	(ii) a panel of other appropriate health care service reviewers with 24
	1451	+	at least one LICENSED physician on the panel who is board certified or eligible in the same 25
	1452	+	specialty as the treatment under review AND KNOWLEDGEABLE AB OUT THE 26
	1453	+	REQUESTED HEALTH CAR E SERVICE OR TREATME NT THROUGH ACTUAL CL INICAL 27
	1454	+	EXPERIENCE ; 28
	1455	+
	1456	+	(2) when the grievance decision involves a dental service, a licensed 29
	1457	+	dentist, or a panel of appropriate health care service reviewers with at least one dentist on 30
	1458	+	the panel who is a licensed dentist, who shall consult with a dentist who is board certified 31
	1459	+	or eligible in the same specialty as the service under review AND KNOWLEDGEABLE 32
	1460	+	ABOUT THE REQUESTED HEALTH CARE SERVICE OR TREATMENT THROUGH ACTUAL 33
	1461	+	CLINICAL EXPERIENCE ; or 34
	1462	+	32 SENATE BILL 791
	1463	+
	1464	+
	1465	+	(3) when the grievance decision involves a mental health or substance 1
	1466	+	abuse service: 2
	1467	+
	1468	+	(i) a licensed physician who: 3
	1469	+
	1470	+	1. is board certified or eligible in the same specialty as the 4
	1471	+	treatment under review; or 5
	1472	+
	1473	+	2. is actively practicing or has demonstrated expertise in the 6
	1474	+	substance abuse or mental health service or treatment under review; or 7
	1475	+
	1476	+	(ii) a panel of other appropriate health care service reviewers with 8
	1477	+	at least one LICENSED physician, selected by the private review agent who: 9
	1478	+
	1479	+	1. is board certified or eligible in the same specialty as the 10
	1480	+	treatment under review; or 11
	1481	+
	1482	+	2. is actively practicing or has demonstrated expertise in the 12
	1483	+	substance abuse or mental health service or treatment under review. 13
	1484	+
	1485	+	SECTION 2. AND BE IT FURTHER ENACTED, That: 14
	1486	+
	1487	+	(a) The Maryland Health Care Commission and the Maryland Insurance 15
	1488	+	Administration, in consultation with health care practitioners and payors of health care 16
	1489	+	services, jointly shall conduct a study on the development of standards for the 17
	1490	+	implementation of payor programs to modify prior authorization requirements for 18
	1491	+	prescription drugs, medical care, and other health care services based on health care 19
	1492	+	practitioner–specific criteria. 20
	1493	+
	1494	+	(b) The study conducted under subsection (a) of this section shall include, through 21
	1495	+	an examination of literature review and legislatively or voluntarily established programs 22
	1496	+	that have been implemented or are being considered in other states, an analysis of: 23
	1497	+
	1498	+	(1) adjustments to payor prior authorization requirements based on a 24
	1499	+	health care practitioner’s: 25
	1500	+
	1501	+	(i) prior approval rates; 26
	1502	+
	1503	+	(ii) ordering and prescribing patterns; and 27
	1504	+
	1505	+	(iii) participation in a payor’s two–sided incentive arrangement or a 28
	1506	+	capitation program; and 29
	1507	+
	1508	+	(2) any other information or metrics necessary to implement the payor 30
	1509	+	programs. 31
	1510	+	SENATE BILL 791 33
	1511	+
	1512	+
	1513	+	(c) On or before December 1, 2024, the Maryland Health Care Commission and 1
	1514	+	the Maryland Insurance Administration jointly shall submit a report to the General 2
	1515	+	Assembly, in accordance with § 2–1257 of the State Government Article, with the findings 3
	1516	+	and recommendations from the study, including recommendations for legislative initiatives 4
	1517	+	necessary for the establishment of payor programs modifying prior authorization 5
	1518	+	requirements based on health care practitioner–specific criteria. 6
	1519	+
	1520	+	SECTION 3. AND BE IT FURTHER ENACTED, That: 7
	1521	+
	1522	+	(a) The Maryland Health Care Commission and the Maryland Insurance 8
	1523	+	Administration jointly shall establish a workgroup to, in consultation with the Maryland 9
	1524	+	Insurance Administration, shall: 10
	1525	+
	1526	+	(1) assess monitor the progress toward implementing the requirements in 11
	1527	+	§ 19–108.5 of the Health – General Article, as enacted by Section 1 of this Act, including 12
	1528	+	monitoring any federal or State developments relating to the requirements; and 13
	1529	+
	1530	+	(2) review issues or recommendations from other states that are 14
	1531	+	implementing a real–time benefit requirement, including establishing a link at the point of 15
	1532	+	prescribing for any available coupons. 16
	1533	+
	1534	+	(b) On or before December 1, 2025, the Maryland Health Care Commission and 17
	1535	+	the Maryland Insurance Administration jointly shall submit a report to shall inform the 18
	1536	+	General Assembly, in accordance with § 2–1257 of the State Government Article, with of 19
	1537	+	any findings and recommendations from the workgroup relating to the implementation of 20
	1538	+	§ 19–108.5 of the Health – General Article, as enacted by Section 1 of this Act. 21
	1539	+
	1540	+	SECTION 4. AND BE IT FURTHER ENACTED, That Section 1 of this Act shall take 22
	1541	+	effect January 1, 2025. 23
	1542	+
	1543	+	SECTION 5. AND BE IT FURTHER ENACTED, That, except as provided in Section 24
	1544	+	4 of this Act, this Act shall take effect July 1, 2024. 25
	1545	+
	1546	+
	1547	+
	1548	+	Approved:
	1549	+	________________________________________________________________________________
	1550	+	Governor.
	1551	+	________________________________________________________________________________
	1552	+	President of the Senate.
	1553	+	________________________________________________________________________________
	1554	+	Speaker of the House of Delegates.