Maryland 2025 Regular Session

Maryland House Bill HB659 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	hb0659
6	6
7	7	HOUSE BILL 659
8	8	J5 5lr2018
9	9	CF SB 475
10	10	By: Delegate Cullison
11	11	Introduced and read first time: January 24, 2025
12	12	Assigned to: Health and Government Operations
13	13
14	14	A BILL ENTITLED
15	15
16	16	AN ACT concerning 1
17	17
18	18	Health Insurance – Utilization Review – Exemption for Participation in 2
19	19	Value–Based Care Arrangements 3
20	20
21	21	FOR the purpose of prohibiting certain carriers from imposing a prior authorization, step 4
22	22	therapy, or quantity limit requirement on eligible providers for health care services 5
23	23	that are included in a two–sided incentive arrangement; and generally relating to 6
24	24	utilization review and value–based care arrangements. 7
25	25
26	26	BY repealing and reenacting, without amendments, 8
27	27	Article – Insurance 9
28	28	Section 15–113(a) 10
29	29	Annotated Code of Maryland 11
30	30	(2017 Replacement Volume and 2024 Supplement) 12
31	31
32	32	BY repealing and reenacting, with amendments, 13
33	33	Article – Insurance 14
34	34	Section 15–113(f) 15
35	35	Annotated Code of Maryland 16
36	36	(2017 Replacement Volume and 2024 Supplement) 17
37	37
38	38	BY adding to 18
39	39	Article – Insurance 19
40	40	Section 15–147 20
41	41	Annotated Code of Maryland 21
42	42	(2017 Replacement Volume and 2024 Supplement) 22
43	43
44	44	SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 23
45	45	That the Laws of Maryland read as follows: 24
46	46
47	47	Article – Insurance 25
48	48	2 HOUSE BILL 659
49	49
50	50
51	51	15–113. 1
52	52
53	53	(a) (1) In this section the following words have the meanings indicated. 2
54	54
55	55	(2) “Carrier” means: 3
56	56
57	57	(i) an insurer; 4
58	58
59	59	(ii) a nonprofit health service plan; 5
60	60
61	61	(iii) a health maintenance organization; 6
62	62
63	63	(iv) a dental plan organization; or 7
64	64
65	65	(v) any other person that provides health benefit plans subject to 8
66	66	regulation by the State. 9
67	67
68	68	(3) “Eligible provider” means: 10
69	69
70	70	(i) a licensed physician, as defined in § 14–101 of the Health 11
71	71	Occupations Article, who voluntarily participates in a two–sided incentive arrangement; or 12
72	72
73	73	(ii) a set of health care practitioners that voluntarily participate in 13
74	74	a two–sided incentive arrangement. 14
75	75
76	76	(4) “Health care practitioner” means an individual who is licensed, 15
77	77	certified, or otherwise authorized under the Health Occupations Article to provide health 16
78	78	care services. 17
79	79
80	80	(5) “Set of health care practitioners” means: 18
81	81
82	82	(i) a group practice; 19
83	83
84	84	(ii) a clinically integrated organization established in accordance 20
85	85	with Subtitle 19 of this title; 21
86	86
87	87	(iii) an accountable care organization established in accordance with 22
88	88	42 U.S.C. § 1395jjj and any applicable federal regulations; or 23
89	89
90	90	(iv) a clinically integrated network that is a provider entity that 24
91	91	meets the criteria established in guidance issued by the Federal Trade Commission, 25
92	92	including a network of behavioral health care programs licensed under § 7.5–401 of the 26
93	93	Health – General Article. 27
94	94
95	95	(6) “Two–sided incentive arrangement” means an arrangement between an 28
96	96	eligible provider and a carrier in which the eligible provider may earn an incentive and a 29 HOUSE BILL 659 3
97	97
98	98
99	99	carrier may recoup funds from the eligible provider in accordance with the terms of a 1
100	100	contract entered into with the eligible provider that meets the requirements of this section. 2
101	101
102	102	(f) (1) Under a two–sided incentive arrangement that complies with the 3
103	103	requirements of this section, a carrier may recoup funds paid to an eligible provider based 4
104	104	on the terms of a written contract between the carrier and the eligible provider that at a 5
105	105	minimum: 6
106	106
107	107	(i) establish a target budget for: 7
108	108
109	109	1. the total cost of care of a population of patients adjusted 8
110	110	for risk and population size; or 9
111	111
112	112	2. the cost of an episode of care; 10
113	113
114	114	(ii) limit recoupment to not more than 50% of the excess above the 11
115	115	mutually agreed on target established in accordance with item (i) of this paragraph; 12
116	116
117	117	(iii) specify a mutually agreed on maximum liability for total 13
118	118	recoupment that may not exceed 10% of the annual payments from the carrier to the eligible 14
119	119	provider; 15
120	120
121	121	(iv) provide an opportunity for gains by an eligible provider that is 16
122	122	greater than the opportunity for recoupment by the carrier; 17
123	123
124	124	(v) following good faith negotiations, provide an opportunity for an 18
125	125	audit by an independent third party and an independent third–party dispute resolution 19
126	126	process; 20
127	127
128	128	(vi) require the carrier and the eligible provider to negotiate in good 21
129	129	faith adjustments to the target budget when: 22
130	130
131	131	1. certain circumstances beyond the control of the carrier or 23
132	132	the eligible provider arise, including changes in hospital rates; and 24
133	133
134	134	2. material changes occur in health care economics, health 25
135	135	care delivery, or regulations that impact the arrangement; and 26
136	136
137	137	(vii) require the carrier to pay any incentive to or request any 27
138	138	recoupment from the eligible provider within 6 months after the end of the contract year, 28
139	139	unless the carrier or eligible provider initiates a dispute relating to the recoupment or 29
140	140	incentive amount. 30
141	141
142	142	(2) Unless mutually agreed to by an eligible provider and a carrier, an 31
143	143	arrangement entered into under this subsection may not provide an opportunity for 32
144	144	recoupment by the carrier based on the eligible provider’s performance during the first 12 33
145	145	months of the arrangement. 34 4 HOUSE BILL 659
146	146
147	147
148	148
149	149	(3) A carrier that enters into a two–sided incentive arrangement with an 1
150	150	eligible provider in which the amount of any payment is determined, in whole or in part, 2
151	151	on the total cost of care of a population of patients or an episode of care, shall, at least 3
152	152	quarterly, disclose to the eligible provider the following information in a manner that meets 4
153	153	federal and State data use and privacy standards: 5
154	154
155	155	(i) any amount paid to another health care provider that is included 6
156	156	in the total cost of care of a patient in the population or episode of care; and 7
157	157
158	158	(ii) any copayment, coinsurance, or deductible that is included in the 8
159	159	total cost of care of a patient in the population or episode of care. 9
160	160
161	161	(4) Unless mutually agreed to by the carrier and eligible provider, a 10
162	162	two–sided incentive arrangement may not be amended during the term of the contract. 11
163	163
164	164	(5) A CARRIER MAY NOT IMPO SE A PRIOR AUTHORIZA TION, STEP 12
165	165	THERAPY, OR QUANTITY LIMIT RE QUIREMENT ON AN ELIG IBLE PROVIDER FOR A 13
166	166	HEALTH CARE SERVICE THAT IS INCLUDED IN A TWO–SIDED INCENTIVE 14
167	167	ARRANGEMENT . 15
168	168
169	169	[(5)] (6) The opportunity for independent third–party dispute resolution 16
170	170	provided for in paragraph (1)(v) of this subsection may not be required to be exhausted 17
171	171	before a member or member’s representative is allowed to file an appeal of a coverage 18
172	172	decision under § 15–10D–02 of this title. 19
173	173
174	174	[(6)] (7) [Nothing in this] THIS subsection may NOT be construed to: 20
175	175
176	176	(i) alter any requirement for a carrier to pay a hospital or related 21
177	177	institution the rate approved by the Health Services Cost Review Commission for hospital 22
178	178	services; or 23
179	179
180	180	(ii) supersede the Health Services Cost Review Commission’s 24
181	181	jurisdiction or authority over rate review and approval for hospital services. 25
182	182
183	183	15–147. 26
184	184
185	185	(A) IN THIS SECTION , “TWO–SIDED INCENTIVE ARRA NGEMENT” HAS THE 27
186	186	MEANING STATED IN § 15–113 OF THIS SUBTITLE. 28
187	187
188	188	(B) THIS SECTION APPLIES TO: 29
189	189
190	190	(1) INSURERS AND NONPROF IT HEALTH SERVICE PL ANS THAT 30
191	191	PROVIDE HOSPITAL , MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GR OUPS 31
192	192	ON AN EXPENSE –INCURRED BASIS UNDER HEALTH INSURANCE POL ICIES OR 32
193	193	CONTRACTS THAT ARE ISSUED OR D ELIVERED IN THE STATE; AND 33 HOUSE BILL 659 5
194	194
195	195
196	196
197	197	(2) HEALTH MAINTENANCE O RGANIZATIONS THAT PR OVIDE 1
198	198	HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GR OUPS UNDER 2
199	199	CONTRACTS THAT ARE I SSUED OR DELIVERED I N THE STATE. 3
200	200
201	201	(C) AN ENTITY SUBJECT TO THIS SECTION MAY NOT IMPO SE A PRIOR 4
202	202	AUTHORIZATION , STEP THERAPY , OR QUANTITY LIMIT REQUIREMENT FOR A 5
203	203	HEALTH CARE SERVICE THAT IS INCLUDED IN A TWO–SIDED INCENTIVE 6
204	204	ARRANGEMENT . 7
205	205
206	206	SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 8
207	207	policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 9
208	208	after January 1, 2026. 10
209	209
210	210	SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 11
211	211	January 1, 2026. 12
212	212