EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*sb0093*
SENATE BILL 93
J5 4lr1215
(PRE–FILED) CF HB 110
By: Senator Augustine
Requested: October 27, 2023
Introduced and read first time: January 10, 2024
Assigned to: Finance
A BILL ENTITLED
AN ACT concerning 1
Health Insurance – Utilization Review – Private Review Agents 2
FOR the purpose of requiring that certain criteria and standards used by private review 3
agents for health insurance utilization review relating to mental health and 4
substance use disorder benefits meet certain requirements; requiring a private 5
review agent to take certain actions before issuing an adverse decision; specifying 6
the procedure for private review agents to follow when making decisions related to 7
mental health and substance use disorder benefits; and generally relating to health 8
insurance and utilization review by private review agents. 9
BY repealing and reenacting, with amendments, 10
Article – Insurance 11
Section 15–10B–02 and 15–10B–05 12
Annotated Code of Maryland 13
(2017 Replacement Volume and 2023 Supplement) 14
BY repealing and reenacting, with amendments, 15
Article – Insurance 16
Section 15–10B–06 17
Annotated Code of Maryland 18
(2017 Replacement Volume and 2023 Supplement) 19
(As enacted by Chapters 364 and 365 of the Acts of the General Assembly of 2023) 20
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 21
That the Laws of Maryland read as follows: 22
Article – Insurance 23
15–10B–02. 24
2 SENATE BILL 93
The purpose of this subtitle is to: 1
(1) promote the delivery of quality health care in a cost effective manner 2
THAT ENSURES TIMELY ACCESS TO HEALTH CAR E SERVICES; 3
(2) foster greater coordination, COMMUNICATION , AND TRANSPARENCY 4
between payors and providers conducting utilization review activities; 5
(3) protect patients, business, and providers by ensuring that private 6
review agents are qualified to perform utilization review activities and to make informed 7
decisions on the appropriateness of medical care; [and] 8
(4) SPECIFY UTILIZATION REVIEW CRITERIA , INCLUDING CRITERIA 9
TO BE USED FOR MENTA L HEALTH AND SUBSTAN CE USE DISORDER BENE FITS; AND 10
[(4)] (5) ensure that private review agents maintain the confidentiality of 11
medical records in accordance with applicable State and federal laws. 12
15–10B–05. 13
(A) (1) IN THIS SECTION THE F OLLOWING WORDS HAVE THE MEANINGS 14
INDICATED. 15
(2) (I) “GENERALLY ACCEPTED ST ANDARDS OF CARE ” MEANS 16
STANDARDS OF CARE AN D CLINICAL PRACTICE THAT ARE GENERALLY R ECOGNIZED 17
BY HEALTH CARE PROVI DERS PRACTICING IN T HE RELEVANT CLINICAL 18
SPECIALTIES. 19
(II) “GENERALLY ACCEPTED ST ANDARDS OF CARE ” INCLUDES 20
STANDARDS REFLECTED IN: 21
1. PEER–REVIEWED SCIENTIFIC STUDIES AND MEDICAL 22
LITERATURE; 23
2. RECOMMENDATIONS OF N ONPROFIT HEALTH CARE 24
PROVIDER PROFESSIONA L ASSOCIATIONS AND S PECIALTY SOCIETIES , INCLUDING 25
PATIENT PLACEMENT CR ITERIA AND CLINICAL PRACTICE GUIDELIN ES; 26
3. RECOMMENDATIONS OF F EDERAL AGENCIES ; AND 27
4. DRUG LABELING APPROV ED BY THE U.S. FOOD AND 28
DRUG ADMINISTRATION . 29
SENATE BILL 93 3
(3) “MENTAL HEALTH DISORDE R” MEANS A DISORDER THA T FALLS 1
UNDER A DIAGNOSTIC C ATEGORY LISTED IN TH E MENTAL, BEHAVIORAL , AND 2
NEURODEVELOPMENTAL DISOR DERS CHAPTER , OR EQUIVALENT CHAPTE R, OF THE 3
CURRENT VERSION OF : 4
(I) THE WORLD HEALTH ORGANIZATION’S INTERNATIONAL 5
STATISTICAL CLASSIFICATION OF DISEASE AND RELATED HEALTH PROBLEMS; OR 6
(II) THE AMERICAN PSYCHIATRIC ASSOCIATION’S DIAGNOSTIC 7
AND STATISTICAL MANUAL OF MENTAL DISORDERS. 8
(4) (I) “SUBSTANCE USE DISORDE R” MEANS A DISORDER THA T 9
FALLS UNDER A DIAGNO STIC CATEGORY LISTED IN THE MENTAL, BEHAVIORAL , AND 10
NEURODEVELOPMENTAL D ISORDERS CHAPTER , OR EQUIVALENT CHAPTE R, OF THE 11
CURRENT VERSION OF : 12
1. THE WORLD HEALTH ORGANIZATION’S 13
INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASE AND RELATED 14
HEALTH PROBLEMS; OR 15
2. THE AMERICAN PSYCHIATRIC ASSOCIATION’S 16
DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS. 17
(II) “SUBSTANCE USE DISORDE R” INCLUDES A 18
SUBSTANCE–RELATED AND ADDICTIV E DISORDER. 19
[(a)] (B) In conjunction with the application, the private review agent shall 20
submit information that the Commissioner requires including: 21
(1) a utilization review plan that includes: 22
(i) the specific criteria and standards to be used in conducting 23
utilization review of proposed or delivered health care services IN ACCORDANCE WITH 24
ITEM (11) OF THIS SUBSECTION ; 25
(II) THE PROCESS FOR CONF IRMING THAT THE SPEC IFIC 26
CRITERIA AND STANDARDS TO B E USED IN CONDUCTING UTILIZATION REVIEW O F 27
PROPOSED OR DELIVERE D MENTAL HEALTH AND SUBSTANCE USE DISORD ER 28
BENEFITS COMPLY WITH ITEM (11) OF THIS SUBSECTION ; 29
[(ii)] (III) those circumstances, if any, under which utilization 30
review may be delegated to a hospital utilization review program; and 31
4 SENATE BILL 93
[(iii)] (IV) if applicable, any provisions by which patients, physicians, 1
or hospitals may seek reconsideration; 2
(2) the type and qualifications of the personnel either employed or under 3
contract to perform the utilization review; 4
(3) a copy of the private review agent’s internal grievance process if a 5
carrier delegates its internal grievance process to the private review agent in accordance 6
with § 15–10A–02(l) of this title; 7
(4) the procedures and policies to ensure that a representative of the 8
private review agent is reasonably accessible to patients and health care providers 7 days 9
a week, 24 hours a day in this State; 10
(5) if applicable, the procedures and policies to ensure that a representative 11
of the private review agent is accessible to health care providers to make all determinations 12
on whether to authorize or certify an emergency inpatient admission, or an admission for 13
residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, 14
emotional, or substance [abuse] USE disorder within 2 hours after receipt of the 15
information necessary to make the determination; 16
(6) the policies and procedures to ensure that all applicable State and 17
federal laws to protect the confidentiality of individual medical records are followed; 18
(7) a copy of the materials designed to inform applicable patients and 19
providers of the requirements of the utilization review plan; 20
(8) a list of the third party payors for which the private review agent is 21
performing utilization review in this State; 22
(9) the policies and procedures to ensure that the private review agent has 23
a formal program for the orientation and training of the personnel either employed or under 24
contract to perform the utilization review; 25
(10) a list of the persons involved in establishing the specific criteria and 26
standards to be used in conducting utilization review; and 27
(11) certification by the private review agent that the criteria and standards 28
to be used in conducting utilization review [are]: 29
(i) FOR PHYSICAL HEALTH CONDITIONS, ARE: 30
1. objective; 31
[(ii)] 2. clinically valid; 32
SENATE BILL 93 5
[(iii)] 3. compatible with established principles of health care; and 1
[(iv)] 4. flexible enough to allow deviations from norms when 2
justified on a case by case basis; 3
(II) FOR SUBSTANCE USE DI SORDERS, ARE IN COMPLIANCE 4
WITH § 15–802(D)(5) OF THIS TITLE; AND 5
(III) FOR MENTAL HEALTH D ISORDERS: 6
1. ARE EVIDENCE –BASED, PEER–REVIEWED, 7
CONSISTENT WITH GENE RALLY ACCEPTED STAND ARDS OF CARE, AND DEVELOPED 8
BY: 9
A. A NONPROFIT PROFESSI ONAL CLINICAL SPECIA LTY 10
SOCIETY FOR MENTAL H EALTH; OR 11
B. FOR CRITERIA NOT WIT HIN THE SCOPE OF THE 12
RELEVANT NONPROFIT P ROFESSIONAL CLINICAL SPECIALTY SOCIETY , AN 13
ORGANIZATION THAT WO RKS DIRECTLY WITH HE ALTH CARE PROVIDERS IN THE 14
SAME SPECIALTY FOR T HE DESIGNATED CRITER IA WHO ARE EMPLOYED OR 15
ENGAGED WITHIN THE O RGANIZATION OR OUTSI DE THE ORGANIZATION TO 16
DEVELOP CLINICAL CRI TERIA, PROVIDED THAT THE OR GANIZATION DOES NOT 17
RECEIVE DIRECT PAYME NTS BASED ON THE OUT COME OR PRIOR AUTHOR IZATION 18
DECISIONS AND DEMONS TRATES THAT ITS CLIN ICAL CRITERIA ARE CO NSISTENT 19
WITH GENERALLY ACCEP TED STANDARDS OF CAR E; 20
2. TAKE INTO ACCOUNT THE NEEDS OF ATYPICAL 21
PATIENT POPULATIONS AND DIAGNOSES ; 22
3. ENSURE QUALITY OF CA RE AND ACCESS TO NEE DED 23
HEALTH CARE SERVICES ; 24
4. ARE SUFFICIENTLY FLE XIBLE TO ALLOW DEVIA TIONS 25
FROM NORMS WHEN JUST IFIED ON A CASE BY C ASE BASIS; 26
5. ARE AGE–APPROPRIATE , CONSIDERING THE UNIQ UE 27
NEEDS OF CHILDREN , ADOLESCENTS , AND OLDER ADULTS ; AND 28
6. ARE EVALUATED AT LEA ST ANNUALLY AND UPDA TED 29
AS NECESSARY . 30
[(b)] (C) On the written request of any person or health care facility, the private 31
review agent shall provide 1 copy of the specific criteria and standards to be used in 32 6 SENATE BILL 93
conducting utilization review of proposed or delivered services and any subsequent 1
revisions, modifications, or additions to the specific criteria and standards to be used in 2
conducting utilization review of proposed or delivered services to the person or health care 3
facility making the request. 4
[(c)] (D) The private review agent may charge a reasonable fee for a copy of the 5
specific criteria and standards or any subsequent revisions, modifications, or additions to 6
the specific criteria to any person or health care facility requesting a copy under subsection 7
[(b)] (C) of this section. 8
[(d)] (E) A private review agent shall advise the Commissioner, in writing, of a 9
change in: 10
(1) ownership, medical director, or chief executive officer within 30 days of 11
the date of the change; 12
(2) the name, address, or telephone number of the private review agent 13
within 30 days of the date of the change; or 14
(3) the private review agent’s scope of responsibility under a contract. 15
15–10B–06. 16
(a) (1) Except as provided in paragraph (4) of this subsection, a private review 17
agent shall: 18
(i) make all initial determinations on whether to authorize or certify 19
a nonemergency course of treatment for a patient within 2 working days after receipt of the 20
information necessary to make the determination; 21
(ii) make all determinations on whether to authorize or certify an 22
extended stay in a health care facility or additional health care services within 1 working 23
day after receipt of the information necessary to make the determination; and 24
(iii) promptly notify the health care provider of the determination. 25
(2) If within 3 calendar days after receipt of the initial request for health 26
care services the private review agent does not have sufficient information to make a 27
determination, the private review agent shall inform the health care provider that 28
additional information must be provided. 29
(3) If a private review agent requires prior authorization for an emergency 30
inpatient admission, or an admission for residential crisis services as defined in § 15–840 31
of this title, for the treatment of a mental, emotional, or substance [abuse] USE disorder, 32
the private review agent shall: 33
SENATE BILL 93 7
(i) make all determinations on whether to authorize or certify an 1
inpatient admission, or an admission for residential crisis services as defined in § 15–840 2
of this title, within 2 hours after receipt of the information necessary to make the 3
determination; and 4
(ii) promptly notify the health care provider of the determination. 5
(4) For a step therapy exception request submitted electronically in 6
accordance with a process established under § 15–142(f) of this title or a prior authorization 7
request submitted electronically for pharmaceutical services, a private review agent shall 8
make a determination: 9
(i) in real time if: 10
1. no additional information is needed by the private review 11
agent to process the request; and 12
2. the request meets the private review agent’s criteria for 13
approval; or 14
(ii) if a request is not approved under item (i) of this paragraph, 15
within 1 business day after the private review agent receives all of the information 16
necessary to make the determination. 17
[(b) If an initial determination is made by a private review agent not to authorize 18
or certify a health care service and the health care provider believes the determination 19
warrants an immediate reconsideration, a private review agent may provide the health 20
care provider the opportunity to speak with the physician that rendered the determination, 21
by telephone on an expedited basis, within a period of time not to exceed 24 hours of the 22
health care provider seeking the reconsideration.] 23
(B) BEFORE ISSUING AN ADV ERSE DECISION , A PRIVATE REVIEW AGE NT 24
SHALL: 25
(1) GIVE THE PATIENT ’S TREATING PHYSICIAN , DENTIST, OR OTHER 26
HEALTH CARE PROVIDER THE OPPORTUNITY TO S PEAK ABOUT THE MEDIC AL 27
NECESSITY OF THE TRE ATMENT REQUEST WITH THE PHYSICIAN , DENTIST, OR 28
PANEL RESPONSIB LE FOR THE ADVERSE D ECISION; AND 29
(2) FOR MENTAL HEALTH AN D SUBSTANCE USE DISO RDER BENEFITS , 30
EXPLAIN HOW THE SPEC IFIC CRITERIA AND ST ANDARDS REQUIRED TO BE USED 31
UNDER § 15–10B–05(B)(11) OF THIS SUBTITLE ARE APPLIED IN THE INDIV IDUAL 32
CASE AND RESULT IN T HE ADVERSE DECISION . 33
(c) For emergency inpatient admissions, a private review agent may not render 34
an adverse decision solely because the hospital did not notify the private review agent of 35 8 SENATE BILL 93
the emergency admission within 24 hours or other prescribed period of time after that 1
admission if the patient’s medical condition prevented the hospital from determining: 2
(1) the patient’s insurance status; and 3
(2) if applicable, the private review agent’s emergency admission 4
notification requirements. 5
(d) (1) Subject to paragraph (2) of this subsection, a private review agent may 6
not render an adverse decision as to an admission of a patient during the first 24 hours 7
after admission when: 8
(i) the admission is based on a determination that the patient is in 9
imminent danger to self or others; 10
(ii) the determination has been made by the patient’s physician or 11
psychologist in conjunction with a member of the medical staff of the facility who has 12
privileges to make the admission; and 13
(iii) the hospital immediately notifies the private review agent of: 14
1. the admission of the patient; and 15
2. the reasons for the admission. 16
(2) A private review agent may not render an adverse decision as to an 17
admission of a patient to a hospital for up to 72 hours, as determined to be medically 18
necessary by the patient’s treating physician, when: 19
(i) the admission is an involuntary admission under §§ 10–615 and 20
10–617(a) of the Health – General Article; and 21
(ii) the hospital immediately notifies the private review agent of: 22
1. the admission of the patient; and 23
2. the reasons for the admission. 24
(e) (1) A private review agent that requires a health care provider to submit a 25
treatment plan in order for the private review agent to conduct utilization review of 26
proposed or delivered services for the treatment of a mental illness, emotional disorder, or 27
a substance [abuse] USE disorder: 28
(i) shall accept: 29
SENATE BILL 93 9
1. the uniform treatment plan form adopted by the 1
Commissioner under § 15–10B–03(d) of this subtitle as a properly submitted treatment 2
plan form; or 3
2. if a service was provided in another state, a treatment plan 4
form mandated by the state in which the service was provided; and 5
(ii) may not impose any requirement to: 6
1. modify the uniform treatment plan form or its content; or 7
2. submit additional treatment plan forms. 8
(2) A uniform treatment plan form submitted under the provisions of this 9
subsection: 10
(i) shall be properly completed by the health care provider; and 11
(ii) may be submitted by electronic transfer. 12
(F) FOR MENTAL HEALTH AND SUBSTANCE USE DISORD ER BENEFITS, A 13
PRIVATE REVIEW AGENT : 14
(1) SHALL USE THE UTILIZ ATION REVIEW CRITERI A REQUIRED TO BE 15
USED UNDER § 15–10B–05(B)(11) OF THIS SUBTITLE FOR ANY DECISION RELATED 16
TO SERVICE INTENSITY , LEVEL OF CARE PLACEM ENT, CONTINUED STAY , TRANSFER, 17
AND DISCHARGE ; 18
(2) SHALL MAKE ALL DECIS IONS CONSISTENT WITH THE REQUIRED 19
CRITERIA FOR CHRONIC CARE TREATMENT ; AND 20
(3) MAY NOT LIMIT TREATM ENT TO SERVICES FOR ACUTE CARE 21
TREATMENT . 22
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 23
January 1, 2025. 24