EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
Underlining indicates amendments to bill.
Strike out indicates matter stricken from the bill by amendment or deleted from the law by
amendment.
*hb0011*
HOUSE BILL 11
J5, J4 5lr1407
(PRE–FILED) CF SB 902
By: Delegate Sample–Hughes Delegates Sample–Hughes, Alston, Bagnall ,
Bhandari, Chisholm, Cullison, Guzzone, Hill, Hutchinson, S. Johnson,
Kaiser, Kerr, Kipke, Lopez, Martinez, M. Morgan, Pena–Melnyk, Reilly,
Rosenberg, Szeliga, Taveras, White Holland, Woods, and Woorman
Requested: October 18, 2024
Introduced and read first time: January 8, 2025
Assigned to: Health and Government Operations
Committee Report: Favorable with amendments
House action: Adopted
Read second time: February 22, 2025
CHAPTER ______
AN ACT concerning 1
Health Insurance – Access to Nonparticipating Providers – Referrals, Additional 2
Assistance, and Coverage 3
FOR the purpose of repealing the termination date for certain provisions of law related to 4
referrals to and reimbursement of specialists and nonphysician specialists who are 5
not part of a carrier’s provider panel; requiring that a certain referral procedure 6
required to be established and implemented by certain insurers, nonprofit health 7
service plans, and health maintenance organizations require the carrier to provide 8
certain assistance to a member in identifying and arranging coverage for a specialist 9
or nonphysician specialist for treatment of a mental health or substance use disorder 10
services; prohibiting certain carriers from imposing prior authorization 11
requirements for scheduling, reimbursing, or continuing an established treatment 12
plan by certain nonparticipating providers utilization review requirements other 13
than what would be required if the covered benefit was provided by a provider on the 14
carrier’s provider panel under certain circumstances; requiring the Maryland Health 15
Care Commission to establish certain reimbursement rates for nonparticipating 16
providers; and generally relating to access to nonparticipating providers. 17
BY repealing and reenacting, without amendments, 18
Article – Insurance 19
Section 15–830(a) 20 2 HOUSE BILL 11
Annotated Code of Maryland 1
(2017 Replacement Volume and 2024 Supplement) 2
BY repealing and reenacting, with amendments, 3
Article – Insurance 4
Section 15–830(d) and (e) 5
Annotated Code of Maryland 6
(2017 Replacement Volume and 2024 Supplement) 7
BY repealing and reenacting, with amendments, 8
Chapter 271 of the Acts of the General Assembly of 2022 9
Section 4 10
BY repealing and reenacting, with amendments, 11
Chapter 272 of the Acts of the General Assembly of 2022 12
Section 4 13
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 14
That the Laws of Maryland read as follows: 15
Article – Insurance 16
15–830. 17
(a) (1) In this section the following words have the meanings indicated. 18
(2) “Carrier” means: 19
(i) an insurer that offers health insurance other than long–term 20
care insurance or disability insurance; 21
(ii) a nonprofit health service plan; 22
(iii) a health maintenance organization; 23
(iv) a dental plan organization; or 24
(v) except for a managed care organization as defined in Title 15, 25
Subtitle 1 of the Health – General Article, any other person that provides health benefit 26
plans subject to State regulation. 27
(3) (i) “Member” means an individual entitled to health care benefits 28
under a policy or plan issued or delivered in the State by a carrier. 29
(ii) “Member” includes a subscriber. 30
(4) “Nonphysician specialist” means a health care provider: 31 HOUSE BILL 11 3
(i) 1. who is not a physician; 1
2. who is licensed or certified under the Health Occupations 2
Article; and 3
3. who is certified or trained to treat or provide health care 4
services for a specified condition or disease in a manner that is within the scope of the 5
license or certification of the health care provider; or 6
(ii) that is licensed as a behavioral health program under § 7.5–401 7
of the Health – General Article. 8
(5) (i) “Provider panel” means the providers that contract with a carrier 9
either directly or through a subcontracting entity to provide health care services to 10
enrollees of the carrier. 11
(ii) “Provider panel” does not include an arrangement in which any 12
provider may participate solely by contracting with the carrier to provide health care 13
services at a discounted fee–for–service rate. 14
(6) “Specialist” means a physician who is certified or trained to practice in 15
a specified field of medicine and who is not designated as a primary care provider by the 16
carrier. 17
(d) (1) Each carrier shall establish and implement a procedure by which a 18
member may request a referral to a specialist or nonphysician specialist who is not part of 19
the carrier’s provider panel in accordance with this subsection. 20
(2) The procedure shall provide for a referral to a specialist or nonphysician 21
specialist who is not part of the carrier’s provider panel if: 22
(i) 1. the member is diagnosed with OR SEEKING CARE FOR a 23
condition or disease that requires specialized health care services or medical care; and 24
(ii) 1. 2. A. the carrier does not have in its provider panel a 25
specialist or nonphysician specialist with the professional training and expertise to treat or 26
provide health care services for the condition or disease; or 27
2. B. the carrier cannot provide reasonable access to a specialist 28
or nonphysician specialist with the professional training and expertise to treat or provide 29
health care services for the condition or disease [without unreasonable delay or travel], 30
INCLUDING WITHIN THE REASONABL E APPOINTMENT WAITIN G TIME AND TRAVEL 31
DISTANCE STANDARDS E STABLISHED IN REGULAT ION FOR MENTAL HEALTH AN D 32
SUBSTANCE USE DISORD ER SERVICES; OR 33
4 HOUSE BILL 11
(II) 1. THE MEMBER IS SEEKIN G MENTAL HEALTH OR 1
SUBSTANCE USE DISORD ER CARE; AND 2
2. THE CARRIER CANNOT P ROVIDE REASONABLE 3
ACCESS TO A SPECIALI ST OR NONPHYSICIAN S PECIALIST WITHIN THE RE ASONABLE 4
APPOINTMENT WAITING TIME AND TRAVEL DIST ANCE STANDARDS ESTAB LISHED IN 5
REGULATION FOR MENTA L HEALTH AND SUBSTAN CE USE DISORDER SERV ICES. 6
(3) The procedure shall ensure that a request to obtain a referral to a 7
specialist or nonphysician specialist who is not part of the carrier’s provider panel is 8
addressed in a timely manner that is: 9
(i) appropriate for the member’s condition; and 10
(ii) in accordance with the timeliness requirements for 11
determinations made by private review agents under § 15–10B–06 of this title. 12
(4) IF A MEMBER CANNOT AC CESS MENTAL HEALTH O R SUBSTANCE 13
USE DISORDER SERVICE S THROUGH THE REFERR AL REQUIREMENTS UNDE R 14
PARAGRAPHS (2) AND (3) OF THIS SUBSECTION , THE PROCEDURE SHALL REQUIRE 15
THE CARRIER TO P ROVIDE ADDITIONAL AS SISTANCE TO THE MEMB ER IN 16
IDENTIFYING AND ARRA NGING COVERAGE OF ME NTAL HEALTH OR SUBST ANCE USE 17
DISORDER SERVICES BY A SPECIALIST OR NONP HYSICIAN SPECIALIST WHO IS NOT 18
PART OF THE CARRIER ’S PROVIDER PANEL . 19
(5) THE PROCEDURE MAY NOT REQUIRE PRIOR AUTHORI ZATION FOR 20
PURPOSES OF: 21
(I) SCHEDULING AN APPOIN TMENT WITH A SPECIAL IST OR 22
NONPHYSICIAN SPECIAL IST WHO IS NOT PART OF THE CARRIER ’S PROVIDER PANEL ; 23
(II) REIMBURSING A SPECIA LIST OR NONPHYSICIAN SPECIALIST 24
WHO IS NOT PART OF T HE CARRIER’S PROVIDER PANEL ; OR 25
(III) CONTINUING AN ESTABL ISHED TREATMENT PLAN WITH A 26
SPECIALIST OR NONPHY SICIAN SPECIALIST WH O IS NOT PART OF THE CARRIER’S 27
PROVIDER PANEL IF A CARRIER APPROVES A MEMBER’S REQUEST FOR A REFE RRAL 28
MADE IN ACCORDANCE W ITH THIS SUBSECTION, THE CARRIER MAY NOT REQUIRE 29
UTILIZATION REVIEW O THER THAN WHAT WOULD BE REQUIRED IF THE C OVERED 30
BENEFIT WERE PROVIDE D BY A PROVIDER ON T HE CARRIER’S PROVIDER PANEL . 31
[(4)] (6) The procedure may not be used by a carrier as a substitute for 32
establishing and maintaining a sufficient provider network in accordance with § 15–112 of 33
this title. 34
HOUSE BILL 11 5
[(5)] (7) Each carrier shall: 1
(i) have a system in place that documents all requests to obtain a 2
referral to receive a covered service from a specialist or nonphysician specialist who is not 3
part of the carrier’s provider panel; 4
(ii) inform members of the procedure to request a referral under 5
paragraph (1) of this subsection; and 6
(iii) provide the information documented under item (i) of this 7
paragraph to the Commissioner on request. 8
(e) (1) Except as provided in paragraph (2) of this subsection, for purposes of 9
calculating any deductible, copayment amount, or coinsurance payable by the member, a 10
carrier shall treat services received in accordance with subsection (d) of this section as if 11
the service was provided by a provider on the carrier’s provider panel. 12
(2) A carrier shall ensure that services received in accordance with 13
subsection (d) of this section for mental health or substance use disorders are provided FOR 14
THE DURATION OF THE TREATMENT PLAN at no greater cost to the covered individual 15
than if the covered benefit were provided by a provider on the carrier’s provider panel. 16
(3) (I) SUBJECT TO SUBPARAGRA PH (II) OF THIS PARAGRAPH , AND 17
NOT LATER THAN JANUARY 1, 2026, THE MARYLAND HEALTH CARE COMMISSION 18
SHALL ESTABLISH A RE IMBURSEMENT FORMULA TO DETERMINE THE 19
REIMBURSEMENT RATE F OR NONPARTICIPATING PROVIDERS WHO DELIVE R 20
SERVICES UNDER PARAG RAPH (2) OF THIS SUBSECTION . 21
(II) THE MARYLAND HEALTH CARE COMMISSION SHALL HOLD 22
PUBLIC MEETINGS WITH CARRIERS, MENTAL HEALTH AND SU BSTANCE USE 23
DISORDER PROVIDERS , CONSUMERS OF MENTAL HEALTH AND SUBSTANCE USE 24
DISORDER SERVICES , AND OTHER INTERESTED PARTIES TO DETERMINE THE 25
REIMBURSEMENT FORMUL A. 26
SECTION 2. AND BE IT FURTHER ENACTED, That the Laws of Maryland read 27
as follows: 28
Chapter 271 of the Acts of 2022 29
SECTION 4. AND BE IT FURTHER ENACTED, That this Act shall take effect July 30
1, 2022. [It shall remain effective for a period of 3 years and, at the end of June 30, 2025, 31
this Act, with no further action required by the General Assembly, shall be abrogated and 32
of no further force and effect.] 33
Chapter 272 of the Acts of 2022 34
6 HOUSE BILL 11
SECTION 4. AND BE IT FURTHER ENACTED, That this Act shall take effect July 1
1, 2022. [It shall remain effective for a period of 3 years and, at the end of June 30, 2025, 2
this Act, with no further action required by the General Assembly, shall be abrogated and 3
of no further force and effect.] 4
SECTION 3. AND BE IT FURTHER ENACTED, That Section 1 of this Act shall 5
apply to all policies, contracts, and health benefit plans issued, delivered, or renewed in the 6
State on or after January 1, 2026. 7
SECTION 4. AND BE IT FURTHER ENACTED, That Section 1 of this Act shall take 8
effect January 1, 2026. 9
SECTION 5. AND BE IT FURTHER ENACTED, That, except as provided in Section 10
4 of this Act, this Act shall take effect June 1, 2025. 11
Approved:
________________________________________________________________________________
Governor.
________________________________________________________________________________
Speaker of the House of Delegates.
________________________________________________________________________________
President of the Senate.