Maryland 2024 Regular Session

Maryland Senate Bill SB93 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2
3	3	EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
4	4	[Brackets] indicate matter deleted from existing law.
5	5	sb0093
6	6
7	7	SENATE BILL 93
8	8	J5 4lr1215
9	9	(PRE–FILED) CF HB 110
10	10	By: Senator Augustine
11	11	Requested: October 27, 2023
12	12	Introduced and read first time: January 10, 2024
13	13	Assigned to: Finance
14	14
15	15	A BILL ENTITLED
16	16
17	17	AN ACT concerning 1
18	18
19	19	Health Insurance – Utilization Review – Private Review Agents 2
20	20
21	21	FOR the purpose of requiring that certain criteria and standards used by private review 3
22	22	agents for health insurance utilization review relating to mental health and 4
23	23	substance use disorder benefits meet certain requirements; requiring a private 5
24	24	review agent to take certain actions before issuing an adverse decision; specifying 6
25	25	the procedure for private review agents to follow when making decisions related to 7
26	26	mental health and substance use disorder benefits; and generally relating to health 8
27	27	insurance and utilization review by private review agents. 9
28	28
29	29	BY repealing and reenacting, with amendments, 10
30	30	Article – Insurance 11
31	31	Section 15–10B–02 and 15–10B–05 12
32	32	Annotated Code of Maryland 13
33	33	(2017 Replacement Volume and 2023 Supplement) 14
34	34
35	35	BY repealing and reenacting, with amendments, 15
36	36	Article – Insurance 16
37	37	Section 15–10B–06 17
38	38	Annotated Code of Maryland 18
39	39	(2017 Replacement Volume and 2023 Supplement) 19
40	40	(As enacted by Chapters 364 and 365 of the Acts of the General Assembly of 2023) 20
41	41
42	42	SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 21
43	43	That the Laws of Maryland read as follows: 22
44	44
45	45	Article – Insurance 23
46	46
47	47	15–10B–02. 24
48	48	2 SENATE BILL 93
49	49
50	50
51	51	The purpose of this subtitle is to: 1
52	52
53	53	(1) promote the delivery of quality health care in a cost effective manner 2
54	54	THAT ENSURES TIMELY ACCESS TO HEALTH CAR E SERVICES; 3
55	55
56	56	(2) foster greater coordination, COMMUNICATION , AND TRANSPARENCY 4
57	57	between payors and providers conducting utilization review activities; 5
58	58
59	59	(3) protect patients, business, and providers by ensuring that private 6
60	60	review agents are qualified to perform utilization review activities and to make informed 7
61	61	decisions on the appropriateness of medical care; [and] 8
62	62
63	63	(4) SPECIFY UTILIZATION REVIEW CRITERIA , INCLUDING CRITERIA 9
64	64	TO BE USED FOR MENTA L HEALTH AND SUBSTAN CE USE DISORDER BENE FITS; AND 10
65	65
66	66	[(4)] (5) ensure that private review agents maintain the confidentiality of 11
67	67	medical records in accordance with applicable State and federal laws. 12
68	68
69	69	15–10B–05. 13
70	70
71	71	(A) (1) IN THIS SECTION THE F OLLOWING WORDS HAVE THE MEANINGS 14
72	72	INDICATED. 15
73	73
74	74	(2) (I) “GENERALLY ACCEPTED ST ANDARDS OF CARE ” MEANS 16
75	75	STANDARDS OF CARE AN D CLINICAL PRACTICE THAT ARE GENERALLY R ECOGNIZED 17
76	76	BY HEALTH CARE PROVI DERS PRACTICING IN T HE RELEVANT CLINICAL 18
77	77	SPECIALTIES. 19
78	78
79	79	(II) “GENERALLY ACCEPTED ST ANDARDS OF CARE ” INCLUDES 20
80	80	STANDARDS REFLECTED IN: 21
81	81
82	82	1. PEER–REVIEWED SCIENTIFIC STUDIES AND MEDICAL 22
83	83	LITERATURE; 23
84	84
85	85	2. RECOMMENDATIONS OF N ONPROFIT HEALTH CARE 24
86	86	PROVIDER PROFESSIONA L ASSOCIATIONS AND S PECIALTY SOCIETIES , INCLUDING 25
87	87	PATIENT PLACEMENT CR ITERIA AND CLINICAL PRACTICE GUIDELIN ES; 26
88	88
89	89	3. RECOMMENDATIONS OF F EDERAL AGENCIES ; AND 27
90	90
91	91	4. DRUG LABELING APPROV ED BY THE U.S. FOOD AND 28
92	92	DRUG ADMINISTRATION . 29
93	93	SENATE BILL 93 3
94	94
95	95
96	96	(3) “MENTAL HEALTH DISORDE R” MEANS A DISORDER THA T FALLS 1
97	97	UNDER A DIAGNOSTIC C ATEGORY LISTED IN TH E MENTAL, BEHAVIORAL , AND 2
98	98	NEURODEVELOPMENTAL DISOR DERS CHAPTER , OR EQUIVALENT CHAPTE R, OF THE 3
99	99	CURRENT VERSION OF : 4
100	100
101	101	(I) THE WORLD HEALTH ORGANIZATION’S INTERNATIONAL 5
102	102	STATISTICAL CLASSIFICATION OF DISEASE AND RELATED HEALTH PROBLEMS; OR 6
103	103
104	104	(II) THE AMERICAN PSYCHIATRIC ASSOCIATION’S DIAGNOSTIC 7
105	105	AND STATISTICAL MANUAL OF MENTAL DISORDERS. 8
106	106
107	107	(4) (I) “SUBSTANCE USE DISORDE R” MEANS A DISORDER THA T 9
108	108	FALLS UNDER A DIAGNO STIC CATEGORY LISTED IN THE MENTAL, BEHAVIORAL , AND 10
109	109	NEURODEVELOPMENTAL D ISORDERS CHAPTER , OR EQUIVALENT CHAPTE R, OF THE 11
110	110	CURRENT VERSION OF : 12
111	111
112	112	1. THE WORLD HEALTH ORGANIZATION’S 13
113	113	INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASE AND RELATED 14
114	114	HEALTH PROBLEMS; OR 15
115	115
116	116	2. THE AMERICAN PSYCHIATRIC ASSOCIATION’S 16
117	117	DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS. 17
118	118
119	119	(II) “SUBSTANCE USE DISORDE R” INCLUDES A 18
120	120	SUBSTANCE–RELATED AND ADDICTIV E DISORDER. 19
121	121
122	122	[(a)] (B) In conjunction with the application, the private review agent shall 20
123	123	submit information that the Commissioner requires including: 21
124	124
125	125	(1) a utilization review plan that includes: 22
126	126
127	127	(i) the specific criteria and standards to be used in conducting 23
128	128	utilization review of proposed or delivered health care services IN ACCORDANCE WITH 24
129	129	ITEM (11) OF THIS SUBSECTION ; 25
130	130
131	131	(II) THE PROCESS FOR CONF IRMING THAT THE SPEC IFIC 26
132	132	CRITERIA AND STANDARDS TO B E USED IN CONDUCTING UTILIZATION REVIEW O F 27
133	133	PROPOSED OR DELIVERE D MENTAL HEALTH AND SUBSTANCE USE DISORD ER 28
134	134	BENEFITS COMPLY WITH ITEM (11) OF THIS SUBSECTION ; 29
135	135
136	136	[(ii)] (III) those circumstances, if any, under which utilization 30
137	137	review may be delegated to a hospital utilization review program; and 31
138	138	4 SENATE BILL 93
139	139
140	140
141	141	[(iii)] (IV) if applicable, any provisions by which patients, physicians, 1
142	142	or hospitals may seek reconsideration; 2
143	143
144	144	(2) the type and qualifications of the personnel either employed or under 3
145	145	contract to perform the utilization review; 4
146	146
147	147	(3) a copy of the private review agent’s internal grievance process if a 5
148	148	carrier delegates its internal grievance process to the private review agent in accordance 6
149	149	with § 15–10A–02(l) of this title; 7
150	150
151	151	(4) the procedures and policies to ensure that a representative of the 8
152	152	private review agent is reasonably accessible to patients and health care providers 7 days 9
153	153	a week, 24 hours a day in this State; 10
154	154
155	155	(5) if applicable, the procedures and policies to ensure that a representative 11
156	156	of the private review agent is accessible to health care providers to make all determinations 12
157	157	on whether to authorize or certify an emergency inpatient admission, or an admission for 13
158	158	residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, 14
159	159	emotional, or substance [abuse] USE disorder within 2 hours after receipt of the 15
160	160	information necessary to make the determination; 16
161	161
162	162	(6) the policies and procedures to ensure that all applicable State and 17
163	163	federal laws to protect the confidentiality of individual medical records are followed; 18
164	164
165	165	(7) a copy of the materials designed to inform applicable patients and 19
166	166	providers of the requirements of the utilization review plan; 20
167	167
168	168	(8) a list of the third party payors for which the private review agent is 21
169	169	performing utilization review in this State; 22
170	170
171	171	(9) the policies and procedures to ensure that the private review agent has 23
172	172	a formal program for the orientation and training of the personnel either employed or under 24
173	173	contract to perform the utilization review; 25
174	174
175	175	(10) a list of the persons involved in establishing the specific criteria and 26
176	176	standards to be used in conducting utilization review; and 27
177	177
178	178	(11) certification by the private review agent that the criteria and standards 28
179	179	to be used in conducting utilization review [are]: 29
180	180
181	181	(i) FOR PHYSICAL HEALTH CONDITIONS, ARE: 30
182	182
183	183	1. objective; 31
184	184
185	185	[(ii)] 2. clinically valid; 32
186	186	SENATE BILL 93 5
187	187
188	188
189	189	[(iii)] 3. compatible with established principles of health care; and 1
190	190
191	191	[(iv)] 4. flexible enough to allow deviations from norms when 2
192	192	justified on a case by case basis; 3
193	193
194	194	(II) FOR SUBSTANCE USE DI SORDERS, ARE IN COMPLIANCE 4
195	195	WITH § 15–802(D)(5) OF THIS TITLE; AND 5
196	196
197	197	(III) FOR MENTAL HEALTH D ISORDERS: 6
198	198
199	199	1. ARE EVIDENCE –BASED, PEER–REVIEWED, 7
200	200	CONSISTENT WITH GENE RALLY ACCEPTED STAND ARDS OF CARE, AND DEVELOPED 8
201	201	BY: 9
202	202
203	203	A. A NONPROFIT PROFESSI ONAL CLINICAL SPECIA LTY 10
204	204	SOCIETY FOR MENTAL H EALTH; OR 11
205	205
206	206	B. FOR CRITERIA NOT WIT HIN THE SCOPE OF THE 12
207	207	RELEVANT NONPROFIT P ROFESSIONAL CLINICAL SPECIALTY SOCIETY , AN 13
208	208	ORGANIZATION THAT WO RKS DIRECTLY WITH HE ALTH CARE PROVIDERS IN THE 14
209	209	SAME SPECIALTY FOR T HE DESIGNATED CRITER IA WHO ARE EMPLOYED OR 15
210	210	ENGAGED WITHIN THE O RGANIZATION OR OUTSI DE THE ORGANIZATION TO 16
211	211	DEVELOP CLINICAL CRI TERIA, PROVIDED THAT THE OR GANIZATION DOES NOT 17
212	212	RECEIVE DIRECT PAYME NTS BASED ON THE OUT COME OR PRIOR AUTHOR IZATION 18
213	213	DECISIONS AND DEMONS TRATES THAT ITS CLIN ICAL CRITERIA ARE CO NSISTENT 19
214	214	WITH GENERALLY ACCEP TED STANDARDS OF CAR E; 20
215	215
216	216	2. TAKE INTO ACCOUNT THE NEEDS OF ATYPICAL 21
217	217	PATIENT POPULATIONS AND DIAGNOSES ; 22
218	218
219	219	3. ENSURE QUALITY OF CA RE AND ACCESS TO NEE DED 23
220	220	HEALTH CARE SERVICES ; 24
221	221
222	222	4. ARE SUFFICIENTLY FLE XIBLE TO ALLOW DEVIA TIONS 25
223	223	FROM NORMS WHEN JUST IFIED ON A CASE BY C ASE BASIS; 26
224	224
225	225	5. ARE AGE–APPROPRIATE , CONSIDERING THE UNIQ UE 27
226	226	NEEDS OF CHILDREN , ADOLESCENTS , AND OLDER ADULTS ; AND 28
227	227
228	228	6. ARE EVALUATED AT LEA ST ANNUALLY AND UPDA TED 29
229	229	AS NECESSARY . 30
230	230
231	231	[(b)] (C) On the written request of any person or health care facility, the private 31
232	232	review agent shall provide 1 copy of the specific criteria and standards to be used in 32 6 SENATE BILL 93
233	233
234	234
235	235	conducting utilization review of proposed or delivered services and any subsequent 1
236	236	revisions, modifications, or additions to the specific criteria and standards to be used in 2
237	237	conducting utilization review of proposed or delivered services to the person or health care 3
238	238	facility making the request. 4
239	239
240	240	[(c)] (D) The private review agent may charge a reasonable fee for a copy of the 5
241	241	specific criteria and standards or any subsequent revisions, modifications, or additions to 6
242	242	the specific criteria to any person or health care facility requesting a copy under subsection 7
243	243	[(b)] (C) of this section. 8
244	244
245	245	[(d)] (E) A private review agent shall advise the Commissioner, in writing, of a 9
246	246	change in: 10
247	247
248	248	(1) ownership, medical director, or chief executive officer within 30 days of 11
249	249	the date of the change; 12
250	250
251	251	(2) the name, address, or telephone number of the private review agent 13
252	252	within 30 days of the date of the change; or 14
253	253
254	254	(3) the private review agent’s scope of responsibility under a contract. 15
255	255
256	256	15–10B–06. 16
257	257
258	258	(a) (1) Except as provided in paragraph (4) of this subsection, a private review 17
259	259	agent shall: 18
260	260
261	261	(i) make all initial determinations on whether to authorize or certify 19
262	262	a nonemergency course of treatment for a patient within 2 working days after receipt of the 20
263	263	information necessary to make the determination; 21
264	264
265	265	(ii) make all determinations on whether to authorize or certify an 22
266	266	extended stay in a health care facility or additional health care services within 1 working 23
267	267	day after receipt of the information necessary to make the determination; and 24
268	268
269	269	(iii) promptly notify the health care provider of the determination. 25
270	270
271	271	(2) If within 3 calendar days after receipt of the initial request for health 26
272	272	care services the private review agent does not have sufficient information to make a 27
273	273	determination, the private review agent shall inform the health care provider that 28
274	274	additional information must be provided. 29
275	275
276	276	(3) If a private review agent requires prior authorization for an emergency 30
277	277	inpatient admission, or an admission for residential crisis services as defined in § 15–840 31
278	278	of this title, for the treatment of a mental, emotional, or substance [abuse] USE disorder, 32
279	279	the private review agent shall: 33
280	280	SENATE BILL 93 7
281	281
282	282
283	283	(i) make all determinations on whether to authorize or certify an 1
284	284	inpatient admission, or an admission for residential crisis services as defined in § 15–840 2
285	285	of this title, within 2 hours after receipt of the information necessary to make the 3
286	286	determination; and 4
287	287
288	288	(ii) promptly notify the health care provider of the determination. 5
289	289
290	290	(4) For a step therapy exception request submitted electronically in 6
291	291	accordance with a process established under § 15–142(f) of this title or a prior authorization 7
292	292	request submitted electronically for pharmaceutical services, a private review agent shall 8
293	293	make a determination: 9
294	294
295	295	(i) in real time if: 10
296	296
297	297	1. no additional information is needed by the private review 11
298	298	agent to process the request; and 12
299	299
300	300	2. the request meets the private review agent’s criteria for 13
301	301	approval; or 14
302	302
303	303	(ii) if a request is not approved under item (i) of this paragraph, 15
304	304	within 1 business day after the private review agent receives all of the information 16
305	305	necessary to make the determination. 17
306	306
307	307	[(b) If an initial determination is made by a private review agent not to authorize 18
308	308	or certify a health care service and the health care provider believes the determination 19
309	309	warrants an immediate reconsideration, a private review agent may provide the health 20
310	310	care provider the opportunity to speak with the physician that rendered the determination, 21
311	311	by telephone on an expedited basis, within a period of time not to exceed 24 hours of the 22
312	312	health care provider seeking the reconsideration.] 23
313	313
314	314	(B) BEFORE ISSUING AN ADV ERSE DECISION , A PRIVATE REVIEW AGE NT 24
315	315	SHALL: 25
316	316
317	317	(1) GIVE THE PATIENT ’S TREATING PHYSICIAN , DENTIST, OR OTHER 26
318	318	HEALTH CARE PROVIDER THE OPPORTUNITY TO S PEAK ABOUT THE MEDIC AL 27
319	319	NECESSITY OF THE TRE ATMENT REQUEST WITH THE PHYSICIAN , DENTIST, OR 28
320	320	PANEL RESPONSIB LE FOR THE ADVERSE D ECISION; AND 29
321	321
322	322	(2) FOR MENTAL HEALTH AN D SUBSTANCE USE DISO RDER BENEFITS , 30
323	323	EXPLAIN HOW THE SPEC IFIC CRITERIA AND ST ANDARDS REQUIRED TO BE USED 31
324	324	UNDER § 15–10B–05(B)(11) OF THIS SUBTITLE ARE APPLIED IN THE INDIV IDUAL 32
325	325	CASE AND RESULT IN T HE ADVERSE DECISION . 33
326	326
327	327	(c) For emergency inpatient admissions, a private review agent may not render 34
328	328	an adverse decision solely because the hospital did not notify the private review agent of 35 8 SENATE BILL 93
329	329
330	330
331	331	the emergency admission within 24 hours or other prescribed period of time after that 1
332	332	admission if the patient’s medical condition prevented the hospital from determining: 2
333	333
334	334	(1) the patient’s insurance status; and 3
335	335
336	336	(2) if applicable, the private review agent’s emergency admission 4
337	337	notification requirements. 5
338	338
339	339	(d) (1) Subject to paragraph (2) of this subsection, a private review agent may 6
340	340	not render an adverse decision as to an admission of a patient during the first 24 hours 7
341	341	after admission when: 8
342	342
343	343	(i) the admission is based on a determination that the patient is in 9
344	344	imminent danger to self or others; 10
345	345
346	346	(ii) the determination has been made by the patient’s physician or 11
347	347	psychologist in conjunction with a member of the medical staff of the facility who has 12
348	348	privileges to make the admission; and 13
349	349
350	350	(iii) the hospital immediately notifies the private review agent of: 14
351	351
352	352	1. the admission of the patient; and 15
353	353
354	354	2. the reasons for the admission. 16
355	355
356	356	(2) A private review agent may not render an adverse decision as to an 17
357	357	admission of a patient to a hospital for up to 72 hours, as determined to be medically 18
358	358	necessary by the patient’s treating physician, when: 19
359	359
360	360	(i) the admission is an involuntary admission under §§ 10–615 and 20
361	361	10–617(a) of the Health – General Article; and 21
362	362
363	363	(ii) the hospital immediately notifies the private review agent of: 22
364	364
365	365	1. the admission of the patient; and 23
366	366
367	367	2. the reasons for the admission. 24
368	368
369	369	(e) (1) A private review agent that requires a health care provider to submit a 25
370	370	treatment plan in order for the private review agent to conduct utilization review of 26
371	371	proposed or delivered services for the treatment of a mental illness, emotional disorder, or 27
372	372	a substance [abuse] USE disorder: 28
373	373
374	374	(i) shall accept: 29
375	375	SENATE BILL 93 9
376	376
377	377
378	378	1. the uniform treatment plan form adopted by the 1
379	379	Commissioner under § 15–10B–03(d) of this subtitle as a properly submitted treatment 2
380	380	plan form; or 3
381	381
382	382	2. if a service was provided in another state, a treatment plan 4
383	383	form mandated by the state in which the service was provided; and 5
384	384
385	385	(ii) may not impose any requirement to: 6
386	386
387	387	1. modify the uniform treatment plan form or its content; or 7
388	388
389	389	2. submit additional treatment plan forms. 8
390	390
391	391	(2) A uniform treatment plan form submitted under the provisions of this 9
392	392	subsection: 10
393	393
394	394	(i) shall be properly completed by the health care provider; and 11
395	395
396	396	(ii) may be submitted by electronic transfer. 12
397	397
398	398	(F) FOR MENTAL HEALTH AND SUBSTANCE USE DISORD ER BENEFITS, A 13
399	399	PRIVATE REVIEW AGENT : 14
400	400
401	401	(1) SHALL USE THE UTILIZ ATION REVIEW CRITERI A REQUIRED TO BE 15
402	402	USED UNDER § 15–10B–05(B)(11) OF THIS SUBTITLE FOR ANY DECISION RELATED 16
403	403	TO SERVICE INTENSITY , LEVEL OF CARE PLACEM ENT, CONTINUED STAY , TRANSFER, 17
404	404	AND DISCHARGE ; 18
405	405
406	406	(2) SHALL MAKE ALL DECIS IONS CONSISTENT WITH THE REQUIRED 19
407	407	CRITERIA FOR CHRONIC CARE TREATMENT ; AND 20
408	408
409	409	(3) MAY NOT LIMIT TREATM ENT TO SERVICES FOR ACUTE CARE 21
410	410	TREATMENT . 22
411	411
412	412	SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 23
413	413	January 1, 2025. 24
414	414