EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*hb1341*
HOUSE BILL 1341
J5 5lr2202
By: Delegates Woods, Bhandari, Kaiser, Kaufman, J. Long, Roberson, Roberts,
Taylor, and White Holland
Introduced and read first time: February 7, 2025
Assigned to: Health and Government Operations
A BILL ENTITLED
AN ACT concerning 1
Health Insurance – Appeals and Adverse Decisions – Call Centers, Notification 2
Requirements, and Required Survey 3
FOR the purpose of requiring health insurance carriers to operate a call center for appeals 4
and adverse decisions, include certain information in a certain manner in the written 5
notice of adverse decisions required to be sent to members, and conduct an annual 6
survey on member experiences with the internal grievance process; and generally 7
relating to health insurance appeals and adverse decisions. 8
BY repealing and reenacting, with amendments, 9
Article – Insurance 10
Section 15–10A–02(e), (f), and (l) and 15–10A–06(a)(3)(viii) and (4) 11
Annotated Code of Maryland 12
(2017 Replacement Volume and 2024 Supplement) 13
BY adding to 14
Article – Insurance 15
Section 15–10A–02(l) and 15–10A–06(a)(5) 16
Annotated Code of Maryland 17
(2017 Replacement Volume and 2024 Supplement) 18
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 19
That the Laws of Maryland read as follows: 20
Article – Insurance 21
15–10A–02. 22
(e) Each carrier shall: 23
2 HOUSE BILL 1341
(1) file for review with the Commissioner and submit to the Health 1
Advocacy Unit a copy of its internal grievance process established under this subtitle; [and] 2
(2) file any revision to the internal grievance process with the 3
Commissioner and the Health Advocacy Unit at least 30 days before its intended use; AND 4
(3) OFFER A 24–HOUR CALL CENTER FOR MEMBERS WHO WISH TO 5
APPEAL AN ADVERSE DE CISION, OPERATED BY STAFF ME MBERS WHO RECEIVE 6
ANNUAL TRAINING IN STATE INSURANCE LAWS AND REGULATIONS . 7
(f) (1) For nonemergency cases, when a carrier renders an adverse decision, 8
the carrier shall: 9
(i) inform the member, the member’s representative, or the health 10
care provider acting on behalf of the member of the adverse decision: 11
1. orally by telephone; or 12
2. with the affirmative consent of the member, the member’s 13
representative, or the health care provider acting on behalf of the member, by text, 14
facsimile, e–mail, an online portal, or other expedited means; and 15
(ii) send, within 5 working days after the adverse decision has been 16
made, a written notice to the member, the member’s representative, and a health care 17
provider acting on behalf of the member that: 18
1. states in detail in clear, understandable language the 19
specific factual bases for the carrier’s decision and the reasoning used to determine that the 20
health care service is not medically necessary and did not meet the carrier’s criteria and 21
standards used in conducting the utilization review; 22
2. provides the specific reference, language, or requirements 23
from the criteria and standards, including any interpretive guidelines, on which the 24
decision was based, and may not solely use: 25
A. generalized terms such as “experimental procedure not 26
covered”, “cosmetic procedure not covered”, “service included under another procedure”, or 27
“not medically necessary”; or 28
B. language directing the member to review the additional 29
coverage criteria in the member’s policy or plan documents; 30
3. states the name, business address, and business telephone 31
number of: 32
A. if the carrier is a health maintenance organization, the 33
medical director or associate medical director, as appropriate, who made the decision; or 34 HOUSE BILL 1341 3
B. if the carrier is not a health maintenance organization, the 1
designated employee or representative of the carrier who has responsibility for the carrier’s 2
internal grievance process and the physician who is required to make all adverse decisions 3
as required in § 15–10B–07(a) of this title; 4
4. gives written details of the carrier’s internal grievance 5
process and procedures under this subtitle; and 6
5. includes the following information: 7
A. that the member, the member’s representative, or a health 8
care provider on behalf of the member has a right to file a complaint with the Commissioner 9
within 4 months after receipt of a carrier’s grievance decision; 10
B. that a complaint may be filed without first filing a 11
grievance if the member, the member’s representative, or a health care provider filing a 12
grievance on behalf of the member can demonstrate a compelling reason to do so as 13
determined by the Commissioner; 14
C. the Commissioner’s address, telephone number, and 15
facsimile number; 16
D. a statement IN 14 POINT BOLD FONT STAT ING THAT 17
THE DECISION IS AN I NSURANCE DENIAL AND that the Health Advocacy Unit is 18
available to assist the member or the member’s representative in both mediating and filing 19
a grievance under the carrier’s internal grievance process; [and] 20
E. the address, telephone number, facsimile number, and 21
electronic mail address of the Health Advocacy Unit IN 14 POINT BOLD FONT; 22
F. THE FOLLOWING STATEM ENT IN 14 POINT BOLD FONT 23
PLACED AT THE TOP OF THE NOTICE: “THIS IS AN INSURANCE DENIAL. FOR FREE 24
HELP, IF YOU DON’T UNDERSTAND THIS DO CUMENT OR YOU WOULD LIKE HELP 25
APPEALING THE DECISI ON, CONTACT THE MARYLAND INSURANCE 26
ADMINISTRATION AT (INSERT THE NUMBER FO R THE ADMINISTRATION ’S MEDICAL 27
NECESSITY AND EMERGENCY APPEALS HOTLINE) OR THROUGH (INSERT THE 28
ADDRESS FOR THE ADMINISTRATION ’S WEBSITE).”; 29
G. A QR CODE THAT LINKS TO A SHORT VIDEO 30
PROVIDING GUIDANCE F OR MEMBERS ON NAVIGAT ING THE GRIEVANCE AN D 31
APPEALS PROCESS ; AND 32
H. THE TELEPHONE NUMBER OF THE CALL CENTER 33
REQUIRED UNDER SUBSE CTION (E)(3) OF THIS SECTION . 34 4 HOUSE BILL 1341
(2) The business telephone number included in the notice as required 1
under paragraph (1)(ii)3 of this subsection must be a dedicated number for adverse 2
decisions and may not be the general customer call number for the carrier. 3
(3) THE COMMISSIONER SHALL DE VELOP THE VIDEO REQU IRED 4
UNDER PARAGRAPH (1)(II)5G OF THIS SUBSECTION . 5
(L) ON AN ANNUAL BASIS, EACH CARRIER SHALL : 6
(1) SURVEY MEMBERS ON TH EIR EXPERIENCES WITH THE CARRIER’S 7
INTERNAL GRIEVANCE P ROCESS, INCLUDING EXPERIENCE S WITH THE CALL 8
CENTERS REQUIRED UND ER SUBSECTION (E)(3) OF THIS SECTION; AND 9
(2) SUBMIT THE RESULTS O F THE SURVEY TO THE COMMISSIONER . 10
[(l)] (M) (1) [Nothing in this] THIS subtitle [prohibits] DOES NOT 11
PROHIBIT a carrier from delegating its internal grievance process to a private review agent 12
that has a certificate issued under Subtitle 10B of this title and is acting on behalf of the 13
carrier. 14
(2) If a carrier delegates its internal grievance process to a private review 15
agent, the carrier shall be: 16
(i) bound by the grievance decision made by the private review 17
agent acting on behalf of the carrier; and 18
(ii) responsible for a violation of any provision of this subtitle 19
regardless of the delegation made by the carrier under paragraph (1) of this subsection. 20
15–10A–06. 21
(a) On a quarterly basis, each carrier shall submit to the Commissioner, on the 22
form the Commissioner requires, a report that describes: 23
(3) the activities of the carrier under this subtitle, including: 24
(viii) the number of requests made and granted under § 15–831(c)(1) 25
and (2) of this title; [and] 26
(4) the number and outcome of all other cases that are not subject to 27
activities of the carrier under this subtitle that resulted from an adverse decision involving 28
the length of stay for inpatient hospitalization as related to the medical procedure involved; 29
AND 30
HOUSE BILL 1341 5
(5) THE AVERAGE HOLD TIME AND TOTAL TIME FOR CALLS MADE TO 1
THE CARRIER ’S GRIEVANCE AND APPE AL CALL CENTERS , SEGREGATED BY 2
EMERGENCY AND NONEME RGENCY CASES . 3
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 4
October 1, 2025. 5