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.
*hb0848*
HOUSE BILL 848
J5 5lr2020
CF SB 474
By: Delegates Pena–Melnyk, Bagnall, Cullison, Kerr, and Rosenberg Rosenberg,
Bhandari, Chisholm, Guzzone, Hill, Hutchinson, S. Johnson, Kaiser, Kipke,
Lopez, Martinez, Reilly, Szeliga, Taveras, White Holland, Woods, and
Woorman
Introduced and read first time: January 30, 2025
Assigned to: Health and Government Operations
Committee Report: Favorable with amendments
House action: Adopted
Read second time: February 25, 2025
CHAPTER ______
AN ACT concerning 1
Health Insurance – Adverse Decisions – Reporting Notices, Reporting, and 2
Examinations 3
FOR the purpose of requiring that certain adverse decision and grievance decision notices 4
include certain information in a certain manner; requiring that certain information 5
submitted to the Maryland Insurance Commissioner by carriers be aggregated by zip 6
code; requiring certain carriers to provide certain information to the Maryland 7
Insurance Commissioner on adverse decisions on types of services that have grown 8
by more than certain percentages or more over certain periods of time; authorizing 9
the Commissioner to use certain adverse decision information as the basis of a 10
certain examination; and generally relating to health insurance and adverse 11
decisions. 12
BY repealing and reenacting, without amendments, 13
Article – Insurance 14
Section 15–10A–02(a) 15
Annotated Code of Maryland 16
(2017 Replacement Volume and 2024 Supplement) 17
BY repealing and reenacting, with amendments, 18
Article – Insurance 19
Section 15–10A–02(f) and (i), 15–10A–06, and 15–10B–05(a)(4) 20 2 HOUSE BILL 848
Annotated Code of Maryland 1
(2017 Replacement Volume and 2024 Supplement) 2
BY adding to 3
Article – Insurance 4
Section 15–10B–05(e) 5
Annotated Code of Maryland 6
(2017 Replacement Volume and 2024 Supplement) 7
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 8
That the Laws of Maryland read as follows: 9
Article – Insurance 10
15–10A–02. 11
(a) Each carrier shall establish an internal grievance process for its members. 12
(f) (1) For nonemergency cases, when a carrier renders an adverse decision, 13
the carrier shall: 14
(i) inform the member, the member’s representative, or the health 15
care provider acting on behalf of the member of the adverse decision: 16
1. orally by telephone; or 17
2. with the affirmative consent of the member, the member’s 18
representative, or the health care provider acting on behalf of the member, by text, 19
facsimile, e–mail, an online portal, or other expedited means; and 20
(ii) send, within 5 working days after the adverse decision has been 21
made, a written notice to the member, the member’s representative, and a health care 22
provider acting on behalf of the member that: 23
1. STATES AT THE TOP IN PROMINENT BOL D PRINT: 24
A. THAT THE NOTICE IS A DENIAL OF A REQUESTE D 25
HEALTH CARE SERVICE ; 26
B. THAT THE MEMBER MAY FILE AN APPEAL; 27
C. THE PHONE NUMBER AND E–MAIL ADDRESS 28
REQUIRED TO BE AVAIL ABLE UNDER § 15–10B–05(E) OF THIS TITLE; AND 29
HOUSE BILL 848 3
D. THAT THE NOTICE INCL UDES ADDITIONAL 1
INFORMATION ON HOW T O FILE AND RECEIVE A SSISTANCE FOR FILING A 2
COMPLAINT; 3
[1.] 2. states in detail in clear, understandable language the 4
specific factual bases for the carrier’s decision and the reasoning used to determine that the 5
health care service is not medically necessary and did not meet the carrier’s criteria and 6
standards used in conducting the utilization review; 7
[2.] 3. provides the specific reference, language, or requirements 8
from the criteria and standards, including any interpretive guidelines, on which the 9
decision was based, and may not solely use: 10
A. generalized terms such as “experimental procedure not 11
covered”, “cosmetic procedure not covered”, “service included under another procedure”, or 12
“not medically necessary”; or 13
B. language directing the member to review the additional 14
coverage criteria in the member’s policy or plan documents; 15
[3.] 4. [states the name,] INCLUDES A UNIQUE ID ENTIFIER 16
FOR AND THE business address[,] and business telephone number of: 17
A. if the carrier is a health maintenance organization, the 18
medical director or associate medical director, as appropriate, who made the decision; or 19
B. if the carrier is not a health maintenance organization, the 20
designated employee or representative of the carrier who has responsibility for the carrier’s 21
internal grievance process and the physician who is required to make all adverse decisions 22
as required in § 15–10B–07(a) of this title; 23
[4.] 5. gives written details of the carrier’s internal grievance 24
process and procedures under this subtitle; and 25
[5.] 6. includes the following information: 26
A. that the member, the member’s representative, or a health 27
care provider on behalf of the member has a right to file a complaint with the Commissioner 28
within 4 months after receipt of a carrier’s grievance decision; 29
B. that a complaint may be filed without first filing a 30
grievance if the member, the member’s representative, or a health care provider filing a 31
grievance on behalf of the member can demonstrate a compelling reason to do so as 32
determined by the Commissioner; 33
4 HOUSE BILL 848
C. the Commissioner’s address, telephone number, and 1
facsimile number; 2
D. a statement that the Health Advocacy Unit is available to 3
assist the member or the member’s representative in both mediating and filing a grievance 4
under the carrier’s internal grievance process; and 5
E. the address, telephone number, facsimile number, and 6
electronic mail address of the Health Advocacy Unit. 7
(2) The business telephone number included in the notice as required 8
under paragraph [(1)(ii)3] (1)(II)4 of this subsection must be a dedicated number for 9
adverse decisions and may not be the general customer call number for the carrier. 10
(i) (1) For nonemergency cases, when a carrier renders a grievance decision, 11
the carrier shall: 12
(i) document the grievance decision in writing after the carrier has 13
provided oral communication of the decision to the member, the member’s representative, 14
or the health care provider acting on behalf of the member; and 15
(ii) send, within 5 working days after the grievance 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 AT THE TOP IN PROMINENT BOLD PRINT : 19
A. THAT THE NOTICE IS A DENIAL OF A REQUESTE D 20
HEALTH CARE SERVICE ; 21
B. THAT THE MEMBER MAY FILE A COMPLAINT WIT H THE 22
COMMISSIONER ; 23
C. THE PHONE NUMBER AND E–MAIL ADDRESS 24
REQUIRED T O BE AVAILABLE UNDER § 15–10B–05(E) OF THIS TITLE; AND 25
D. THAT THE NOTICE INCL UDES ADDITIONAL 26
INFORMATION ON HOW T O FILE AND RECEIVE A SSISTANCE FOR AN APP EAL; 27
[1.] 2. states in detail in clear, understandable language the 28
specific factual bases for the carrier’s decision and the reasoning used to determine that the 29
health care service is not medically necessary and did not meet the carrier’s criteria and 30
standards used in conducting utilization review; 31
HOUSE BILL 848 5
[2.] 3. provides the specific reference, language, or requirements 1
from the criteria and standards, including any interpretive guidelines used by the carrier, 2
on which the grievance decision was based; 3
[3.] 4. [states the name,] INCLUDES A UNIQUE ID ENTIFIER 4
FOR AND THE business address[,] and business telephone number of: 5
A. if the carrier is a health maintenance organization, the 6
medical director or associate medical director, as appropriate, who made the grievance 7
decision; or 8
B. if the carrier is not a health maintenance organization, the 9
designated employee or representative of the carrier who has responsibility for the carrier’s 10
internal grievance process and the designated employee or representative’s title and 11
clinical specialty; and 12
[4.] 5. includes the following information: 13
A. that the member or the member’s representative has a 14
right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s 15
grievance decision; 16
B. the Commissioner’s address, telephone number, and 17
facsimile number; 18
C. a statement that the Health Advocacy Unit is available to 19
assist the member or the member’s representative in filing a complaint with the 20
Commissioner; and 21
D. the address, telephone number, facsimile number, and 22
electronic mail address of the Health Advocacy Unit. 23
(2) The business telephone number included in the notice as required 24
under paragraph [(1)(ii)3] (1)(II)4 of this subsection must be a dedicated number for 25
grievance decisions and may not be the general customer call number for the carrier. 26
(3) To satisfy the requirements of this subsection, a carrier may not use 27
solely in the written notice sent under paragraph (1) of this subsection: 28
(i) generalized terms such as “experimental procedure not covered”, 29
“cosmetic procedure not covered”, “service included under another procedure”, or “not 30
medically necessary”; or 31
(ii) language directing the member to review the additional coverage 32
criteria in the member’s policy or plan documents. 33
15–10A–06. 34 6 HOUSE BILL 848
(a) (1) On a quarterly basis, each carrier shall submit to the Commissioner, on 1
the form the Commissioner requires, a report that describes THE FOLLOWING 2
INFORMATION AGGREGAT ED BY ZIP CODE AS RE QUIRED BY THE COMMISSIONER : 3
[(1)] (I) the number of members entitled to health care benefits under a 4
policy, plan, or certificate issued or delivered in the State by the carrier; 5
[(2)] (II) the number of clean claims for reimbursement processed by the 6
carrier; 7
[(3)] (III) the activities of the carrier under this subtitle, including: 8
[(i)] 1. the outcome of each grievance filed with the carrier; 9
[(ii)] 2. the number and outcomes of cases that were considered 10
emergency cases under § 15–10A–02(b)(2)(i) of this subtitle; 11
[(iii)] 3. the time within which the carrier made a grievance 12
decision on each emergency case; 13
[(iv)] 4. the time within which the carrier made a grievance 14
decision on all other cases that were not considered emergency cases; 15
[(v)] 5. the number of grievances filed with the carrier that 16
resulted from an adverse decision involving length of stay for inpatient hospitalization as 17
related to the medical procedure involved; 18
[(vi)] 6. the number of adverse decisions issued by the carrier 19
under § 15–10A–02(f) of this subtitle, whether the adverse decision involved a prior 20
authorization or step therapy protocol, and the type of service at issue in the adverse 21
decisions; 22
[(vii)] 7. the number of adverse decisions overturned after a 23
reconsideration request under § 15–10B–06 of this title; and 24
[(viii)] 8. the number of requests made and granted under § 25
15–831(c)(1) and (2) of this title; and 26
[(4)] (IV) 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
(2) IF THE NUMBER OF ADVE RSE DECISIONS ISSUED BY A CARRIER 30
FOR A TYPE OF SERVIC E HAS GROWN BY MORE THAN 10% OR MORE IN THE 31 HOUSE BILL 848 7
IMMEDIATELY PRECEDIN G CALENDAR YEAR OR 25% OR MORE IN THE IMMEDIATELY 1
PRECEDING 3 CALENDAR YEARS , THE CARRIER SHALL SU BMIT IN THE REPORT 2
REQUIRED UNDER PARAG RAPH (1) OF THIS SUBSECTION : 3
(I) A DESCRIPTION OF ANY CHANGES IN MEDICAL 4
MANAGEMENT CON TRIBUTING TO THE RIS E IN ADVERSE DECISIO NS FOR THE TYPE 5
OF SERVICE; AND 6
(II) ANY OTHER KNOWN REAS ONS FOR THE INCREASE ; AND 7
(III) A DESCRIPTION OF THE CARRIER’S EFFORTS AND ACTION S 8
TAKEN TO DETERMINE T HE REASON FOR THE IN CREASE. 9
(b) The Commissioner shall: 10
(1) compile an annual summary report based on the information provided: 11
(i) under subsection (a) of this section; and 12
(ii) by the Secretary under § 19–705.2(e) of the Health – General 13
Article; 14
(2) report any violations or actions taken under § 15–10B–11 of this title; 15
and 16
(3) provide copies of the summary report to the Governor and, subject to § 17
2–1257 of the State Government Article, to the General Assembly. 18
(C) THE COMMISSIONER MAY USE INFORMATION PROVIDED UNDER 19
SUBSECTION (A) OF THIS SECTION AS T HE BASIS FOR AN EXAM INATION UNDER 20
TITLE 2, SUBTITLE 2 OF THIS ARTICLE. 21
15–10B–05. 22
(a) In conjunction with the application, the private review agent shall submit 23
information that the Commissioner requires including: 24
(4) the procedures and policies to ensure that a representative of the 25
private review agent is reasonably accessible to patients and health care providers 7 days 26
a week, 24 hours a day in this State INCLUDING HAVING A D IRECT PHONE NUMBER 27
AND MONITORED E –MAIL AS REQUIRED IN SUBSECTION (E) OF THIS SECTION ; 28
(E) (1) A PRIVATE REVIEW AGENT SHALL: 29
(I) HAVE AVAILABLE THE F OLLOWING DEDICATED T O 30
UTILIZATION REVIEW : 31 8 HOUSE BILL 848
1. A DIRECT TELEPHONE N UMBER THAT IS NOT THE 1
GENERAL CUSTOMER CAL L NUMBER; AND 2
2. A MONITORED E –MAIL ADDRESS ; AND 3
(II) RESPOND TO VOICEMAIL S OR E–MAILS WITHIN 2 BUSINESS 4
DAYS AFTER RECEIPT O F THE VOICEMAIL OR E –MAIL. 5
(2) THE PHONE NUMBER AND E–MAIL ADDRESS SHALL B E 6
PROMINENTLY DISPLAYED ON THE NOT ICES REQUIRED UNDER § 15–10A–02(F) AND 7
(I) OF THIS TITLE. 8
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 9
October 1, 2025. 10
Approved:
________________________________________________________________________________
Governor.
________________________________________________________________________________
Speaker of the House of Delegates.
________________________________________________________________________________
President of the Senate.