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.
Italics indicate opposite chamber/conference committee amendments.
*hb0848*
HOUSE BILL 848
J5 (5lr2020)
ENROLLED BILL
— Health and Government Operations/Finance —
Introduced 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
Read and Examined by Proofreaders:
_______________________________________________
Proofreader.
_______________________________________________
Proofreader.
Sealed with the Great Seal and presented to the Governor, for his approval this
_______ day of _______________ at ________________________ o’clock, ________M.
______________________________________________
Speaker.
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 the information 5
regarding criteria and standards for utilization review that a private review agent is 6
required to post on its website or the carrier’s website be posted on the member’s and 7
provider’s pages of the websites; requiring that certain information submitted to the 8
Maryland Insurance Commissioner by carriers be aggregated by zip code; requiring 9
certain carriers to provide certain information to the Maryland Insurance 10
Commissioner on adverse decisions on types of services that have grown by more 11
than certain percentages or more over certain periods of time; authorizing the 12 2 HOUSE BILL 848
Commissioner to use certain adverse decision information as the basis of a certain 1
examination; requiring private review agents to have a certain telephone number and 2
e–mail address dedicated to utilization review that will be responded to within a 3
certain period of time; and generally relating to health insurance and adverse 4
decisions. 5
BY repealing and reenacting, without amendments, 6
Article – Insurance 7
Section 15–10A–02(a) 8
Annotated Code of Maryland 9
(2017 Replacement Volume and 2024 Supplement) 10
BY repealing and reenacting, with amendments, 11
Article – Insurance 12
Section 15–10A–02(f) and (i), 15–10A–06, and 15–10B–05(a)(4) and (b) 13
Annotated Code of Maryland 14
(2017 Replacement Volume and 2024 Supplement) 15
BY repealing and reenacting, with amendments, 16
Article – Insurance 17
Section 15–10A–02(f) and (i) 18
Annotated Code of Maryland 19
(2017 Replacement Volume and 2024 Supplement) 20
(As enacted by Section 1 of this Act) 21
BY adding to 22
Article – Insurance 23
Section 15–10B–05(e) 24
Annotated Code of Maryland 25
(2017 Replacement Volume and 2024 Supplement) 26
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 27
That the Laws of Maryland read as follows: 28
Article – Insurance 29
15–10A–02. 30
(a) Each carrier shall establish an internal grievance process for its members. 31
(f) (1) For nonemergency cases, when a carrier renders an adverse decision, the 32
carrier shall: 33
(i) inform the member, the member’s representative, or the health 34
care provider acting on behalf of the member of the adverse decision: 35
1. orally by telephone; or 36 HOUSE BILL 848 3
2. with the affirmative consent of the member, the member’s 1
representative, or the health care provider acting on behalf of the member, by text, facsimile, 2
e–mail, an online portal, or other expedited means; and 3
(ii) send, within 5 working days after the adverse decision has been 4
made, a written notice to the member, the member’s representative, and a health care 5
provider acting on behalf of the member that: 6
1. states in detail in clear, understandable language the 7
specific factual bases for the carrier’s decision and the reasoning used to determine that the 8
health care service is not medically necessary and did not meet the carrier’s criteria and 9
standards used in conducting the utilization review; 10
2. provides the specific reference, language, or requirements 11
from the criteria and standards, including any interpretive guidelines, on which the decision 12
was based, and may not solely use: 13
A. generalized terms such as “experimental procedure not 14
covered”, “cosmetic procedure not covered”, “service included under another procedure”, or 15
“not medically necessary”; or 16
B. language directing the member to review the additional 17
coverage criteria in the member’s policy or plan documents; 18
3. [states the name,] INCLUDES A UNIQUE ID ENTIFIER 19
FOR AND THE business address[,] and business telephone number of: 20
A. if the carrier is a health maintenance organization, the 21
medical director or associate medical director, as appropriate, who made the decision; or 22
B. if the carrier is not a health maintenance organization, the 23
designated employee or representative of the carrier who has responsibility for the carrier’s 24
internal grievance process and the physician who is required to make all adverse decisions 25
as required in § 15–10B–07(a) of this title; 26
4. gives written details of the carrier’s internal grievance 27
process and procedures under this subtitle; and 28
5. includes the following information: 29
A. that the member, the member’s representative, or a health 30
care provider on behalf of the member has a right to file a complaint with the Commissioner 31
within 4 months after receipt of a carrier’s grievance decision; 32
B. that a complaint may be filed without first filing a 33
grievance if the member, the member’s representative, or a health care provider filing a 34 4 HOUSE BILL 848
grievance on behalf of the member can demonstrate a compelling reason to do so as 1
determined by the Commissioner; 2
C. the Commissioner’s address, telephone number, and 3
facsimile number; 4
D. a statement that the Health Advocacy Unit is available to 5
assist the member or the member’s representative in both mediating and filing a grievance 6
under the carrier’s internal grievance process; and 7
E. the address, telephone number, facsimile number, and 8
electronic mail address of the Health Advocacy Unit. 9
(2) The business telephone number included in the notice as required under 10
paragraph (1)(ii)3 of this subsection must be a dedicated number for adverse decisions and 11
may not be the general customer call number for the carrier. 12
(i) (1) For nonemergency cases, when a carrier renders a grievance decision, 13
the carrier shall: 14
(i) document the grievance decision in writing after the carrier has 15
provided oral communication of the decision to the member, the member’s representative, or 16
the health care provider acting on behalf of the member; and 17
(ii) send, within 5 working days after the grievance decision has been 18
made, a written notice to the member, the member’s representative, and a health care 19
provider acting on behalf of the member that: 20
1. states in detail in clear, understandable language the 21
specific factual bases for the carrier’s decision and the reasoning used to determine that the 22
health care service is not medically necessary and did not meet the carrier’s criteria and 23
standards used in conducting utilization review; 24
2. provides the specific reference, language, or requirements 25
from the criteria and standards, including any interpretive guidelines used by the carrier, 26
on which the grievance decision was based; 27
3. [states the name,] INCLUDES A UNIQUE ID ENTIFIER 28
FOR AND THE business address[,] and business telephone number of: 29
A. if the carrier is a health maintenance organization, the 30
medical director or associate medical director, as appropriate, who made the grievance 31
decision; or 32
B. if the carrier is not a health maintenance organization, the 33
designated employee or representative of the carrier who has responsibility for the carrier’s 34 HOUSE BILL 848 5
internal grievance process and the designated employee or representative’s title and clinical 1
specialty; and 2
4. includes the following information: 3
A. that the member or the member’s representative has a right 4
to file a complaint with the Commissioner within 4 months after receipt of a carrier’s 5
grievance decision; 6
B. the Commissioner’s address, telephone number, and 7
facsimile number; 8
C. a statement that the Health Advocacy Unit is available to 9
assist the member or the member’s representative in filing a complaint with the 10
Commissioner; and 11
D. the address, telephone number, facsimile number, and 12
electronic mail address of the Health Advocacy Unit. 13
(2) The business telephone number included in the notice as required under 14
paragraph (1)(ii)3 of this subsection must be a dedicated number for grievance decisions and 15
may not be the general customer call number for the carrier. 16
(3) To satisfy the requirements of this subsection, a carrier may not use 17
solely in the written notice sent under paragraph (1) of this subsection: 18
(i) generalized terms such as “experimental procedure not covered”, 19
“cosmetic procedure not covered”, “service included under another procedure”, or “not 20
medically necessary”; or 21
(ii) language directing the member to review the additional coverage 22
criteria in the member’s policy or plan documents. 23
15–10B–05. 24
(b) The private review agent shall: 25
(1) post on THE MEMBER ’S AND PROVIDER ’S PAGES OF its website or the 26
carrier’s website the specific criteria and standards to be used in conducting utilization 27
review of proposed or delivered services and any subsequent revisions, modifications, or 28
additions to the specific criteria and standards to be used in conducting utilization review 29
of proposed or delivered services; and 30
(2) on the request of a person, including a health care facility, provide a copy 31
of the information specified under item (1) of this subsection to the person making the 32
request. 33
6 HOUSE BILL 848
SECTION 2. AND BE IT FURTHER ENACTED, That the Laws of Maryland read 1
as follows: 2
Article – Insurance 3
15–10A–02. 4
(a) Each carrier shall establish an internal grievance process for its members. 5
(f) (1) For nonemergency cases, when a carrier renders an adverse decision, 6
the carrier shall: 7
(i) inform the member, the member’s representative, or the health 8
care provider acting on behalf of the member of the adverse decision: 9
1. orally by telephone; or 10
2. with the affirmative consent of the member, the member’s 11
representative, or the health care provider acting on behalf of the member, by text, 12
facsimile, e–mail, an online portal, or other expedited means; and 13
(ii) send, within 5 working days after the adverse decision has been 14
made, a written notice to the member, the member’s representative, and a health care 15
provider acting on behalf of the member that: 16
1. STATES AT THE TOP IN PROMINENT BOLD PRINT : 17
A. THAT THE NOTICE IS A DENIAL OF A REQUESTE D 18
HEALTH CARE SERVICE ; 19
B. THAT THE MEMBER MAY FILE AN APPEAL; 20
C. THE PHONE TELEPHONE NUMBER AND E –MAIL 21
ADDRESS REQUIRED TO BE AVAILABLE UNDER § 15–10B–05(E) OF THIS TITLE; AND 22
D. THAT THE NOTICE INCLUDES ADDITIONAL 23
INFORMATION ON HOW T O FILE AND RECEIVE A SSISTANCE FOR FILING A 24
COMPLAINT; 25
[1.] 2. states in detail in clear, understandable language the 26
specific factual bases for the carrier’s decision and the reasoning used to determine that the 27
health care service is not medically necessary and did not meet the carrier’s criteria and 28
standards used in conducting the utilization review; 29
HOUSE BILL 848 7
[2.] 3. provides the specific reference, language, or requirements 1
from the criteria and standards, including any interpretive guidelines, on which the 2
decision was based, and may not solely use: 3
A. generalized terms such as “experimental procedure not 4
covered”, “cosmetic procedure not covered”, “service included under another procedure”, or 5
“not medically necessary”; or 6
B. language directing the member to review the additional 7
coverage criteria in the member’s policy or plan documents; 8
[3.] 4. [states the name,] INCLUDES A UNIQUE ID ENTIFIER 9
FOR AND THE INCLUDES A UNIQUE ID ENTIFIER FOR AND THE business address[,] and 10
business telephone number of: 11
A. if the carrier is a health maintenance organization, the 12
medical director or associate medical director, as appropriate, who made the decision; or 13
B. if the carrier is not a health maintenance organization, the 14
designated employee or representative of the carrier who has responsibility for the carrier’s 15
internal grievance process and the physician who is required to make all adverse decisions 16
as required in § 15–10B–07(a) of this title; 17
[4.] 5. gives written details of the carrier’s internal grievance 18
process and procedures under this subtitle; and 19
[5.] 6. includes the following information: 20
A. that the member, the member’s representative, or a health 21
care provider on behalf of the member has a right to file a complaint with the Commissioner 22
within 4 months after receipt of a carrier’s grievance decision; 23
B. that a complaint may be filed without first filing a 24
grievance if the member, the member’s representative, or a health care provider filing a 25
grievance on behalf of the member can demonstrate a compelling reason to do so as 26
determined by the Commissioner; 27
C. the Commissioner’s address, telephone number, and 28
facsimile number; 29
D. a statement that the Health Advocacy Unit is available to 30
assist the member or the member’s representative in both mediating and filing a grievance 31
under the carrier’s internal grievance process; and 32
E. the address, telephone number, facsimile number, and 33
electronic mail address of the Health Advocacy Unit. 34 8 HOUSE BILL 848
(2) The business telephone number included in the notice as required 1
under paragraph [(1)(ii)3] (1)(II)4 of this subsection must be a dedicated number for 2
adverse decisions and may not be the general customer call number for the carrier. 3
(i) (1) For nonemergency cases, when a carrier renders a grievance decision, 4
the carrier shall: 5
(i) document the grievance decision in writing after the carrier has 6
provided oral communication of the decision to the member, the member’s representative, 7
or the health care provider acting on behalf of the member; and 8
(ii) send, within 5 working days after the grievance decision has been 9
made, a written notice to the member, the member’s representative, and a health care 10
provider acting on behalf of the member that: 11
1. STATES AT THE TOP IN PROMINENT BOLD PRINT : 12
A. THAT THE NOTICE IS A DENIAL OF A REQUESTE D 13
HEALTH CARE SERVICE ; 14
B. THAT THE MEMBER MAY FILE A COMPLAINT WIT H THE 15
COMMISSIONER ; 16
C. THE PHONE TELEPHONE NUMBER AND E –MAIL 17
ADDRESS REQUIRED TO BE AVAILABLE UNDER § 15–10B–05(E) OF THIS TITLE; AND 18
D. THAT THE NOTICE INCL UDES ADDITIONAL 19
INFORMATION ON HOW T O FILE AND RECEIVE A SSISTANCE FOR AN APP EAL; 20
[1.] 2. states in detail in clear, understandable language the 21
specific factual bases for the carrier’s decision and the reasoning used to determine that the 22
health care service is not medically necessary and did not meet the carrier’s criteria and 23
standards used in conducting utilization review; 24
[2.] 3. provides the specific reference, language, or requirements 25
from the criteria and standards, including any interpretive guidelines used by the carrier, 26
on which the grievance decision was based; 27
[3.] 4. [states the name,] INCLUDES A UNIQUE ID ENTIFIER 28
FOR AND THE INCLUDES A UNIQUE ID ENTIFIER FOR AND THE business address[,] and 29
business telephone number of: 30
A. if the carrier is a health maintenance organization, the 31
medical director or associate medical director, as appropriate, who made the grievance 32
decision; or 33 HOUSE BILL 848 9
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 designated employee or representative’s title and 3
clinical specialty; and 4
[4.] 5. includes the following information: 5
A. that the member or the member’s representative has a 6
right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s 7
grievance decision; 8
B. the Commissioner’s address, telephone number, and 9
facsimile number; 10
C. a statement that the Health Advocacy Unit is available to 11
assist the member or the member’s representative in filing a complaint with the 12
Commissioner; and 13
D. the address, telephone number, facsimile number, and 14
electronic mail address of the Health Advocacy Unit. 15
(2) The business telephone number included in the notice as required 16
under paragraph [(1)(ii)3] (1)(II)4 of this subsection must be a dedicated number for 17
grievance decisions and may not be the general customer call number for the carrier. 18
(3) To satisfy the requirements of this subsection, a carrier may not use 19
solely in the written notice sent under paragraph (1) of this subsection: 20
(i) generalized terms such as “experimental procedure not covered”, 21
“cosmetic procedure not covered”, “service included under another procedure”, or “not 22
medically necessary”; or 23
(ii) language directing the member to review the additional coverage 24
criteria in the member’s policy or plan documents. 25
15–10A–06. 26
(a) (1) On a quarterly basis, each carrier shall submit to the Commissioner, on 27
the form the Commissioner requires, a report that describes THE FOLLOWING 28
INFORMATION AGGREGAT ED BY ZIP CODE AS RE QUIRED BY THE COMMISSIONER : 29
[(1)] (I) the number of members entitled to health care benefits under a 30
policy, plan, or certificate issued or delivered in the State by the carrier; 31
10 HOUSE BILL 848
[(2)] (II) the number of clean claims for reimbursement processed by the 1
carrier; 2
[(3)] (III) the activities of the carrier under this subtitle, including: 3
[(i)] 1. the outcome of each grievance filed with the carrier; 4
[(ii)] 2. the number and outcomes of cases that were considered 5
emergency cases under § 15–10A–02(b)(2)(i) of this subtitle; 6
[(iii)] 3. the time within which the carrier made a grievance 7
decision on each emergency case; 8
[(iv)] 4. the time within which the carrier made a grievance 9
decision on all other cases that were not considered emergency cases; 10
[(v)] 5. the number of grievances filed with the carrier that 11
resulted from an adverse decision involving length of stay for inpatient hospitalization as 12
related to the medical procedure involved; 13
[(vi)] 6. the number of adverse decisions issued by the carrier 14
under § 15–10A–02(f) of this subtitle, whether the adverse decision involved a prior 15
authorization or step therapy protocol, and the type of service at issue in the adverse 16
decisions; 17
[(vii)] 7. the number of adverse decisions overturned after a 18
reconsideration request under § 15–10B–06 of this title; and 19
[(viii)] 8. the number of requests made and granted under § 20
15–831(c)(1) and (2) of this title; and 21
[(4)] (IV) the number and outcome of all other cases that are not subject to 22
activities of the carrier under this subtitle that resulted from an adverse decision involving 23
the length of stay for inpatient hospitalization as related to the medical procedure involved. 24
(2) IF THE NUMBER OF ADVE RSE DECISIONS ISSUED BY A CARRIER 25
FOR A TYPE OF SERVIC E HAS GROWN BY MORE THAN 10% OR MORE IN THE 26
IMMEDIATELY PRECEDIN G CALENDAR YEAR OR 25% OR MORE IN THE IMMEDIATELY 27
PRECEDING 3 CALENDAR YEARS , THE CARRIER SHALL SU BMIT IN THE REPORT 28
REQUIRED UNDER PARAG RAPH (1) OF THIS SUBSECTION : 29
(I) A DESCRIPTION OF ANY CHANGES IN MEDICAL 30
MANAGEMENT CONTRIBUT ING TO THE RISE IN AD VERSE DECISIONS FOR THE TYPE 31
OF SERVICE; AND 32
HOUSE BILL 848 11
(II) ANY OTHER KNOWN REAS ONS FOR THE INCREASE ; AND 1
(III) A DESCRIPTION OF THE CARRIER’S EFFORTS AND ACTION S 2
TAKEN TO DETERMINE T HE REASON FOR THE IN CREASE. 3
(b) The Commissioner shall: 4
(1) compile an annual summary report based on the information provided: 5
(i) under subsection (a) of this section; and 6
(ii) by the Secretary under § 19–705.2(e) of the Health – General 7
Article; 8
(2) report any violations or actions taken under § 15–10B–11 of this title; 9
and 10
(3) provide copies of the summary report to the Governor and, subject to § 11
2–1257 of the State Government Article, to the General Assembly. 12
(C) THE COMMISSIONER MAY USE INFORMATION PROVIDED UNDER 13
SUBSECTION (A) OF THIS SECTION AS THE BASIS FOR AN EXAMINA TION UNDER 14
TITLE 2, SUBTITLE 2 OF THIS ARTICLE. 15
15–10B–05. 16
(a) In conjunction with the application, the private review agent shall submit 17
information that the Commissioner requires including: 18
(4) the procedures and policies to ensure that a representative of the 19
private review agent is reasonably accessible to patients and health care providers 7 days 20
a week, 24 hours a day in this State INCLUDING HAVING A D IRECT PHONE TELEPHONE 21
NUMBER AND MONITORE D E–MAIL ADDRESS AS REQUIRED IN SUBSE CTION (E) OF 22
THIS SECTION; 23
(E) (1) A PRIVATE REVIEW AGENT SHALL: 24
(I) HAVE AVAILABLE THE F OLLOWING DEDICATED T O 25
UTILIZATION REVIEW : 26
1. A DIRECT TELEPHONE N UMBER THAT IS NOT TH E 27
GENERAL CUSTOMER CAL L NUMBER; AND 28
2. A MONITORED E –MAIL ADDRESS ; AND 29
12 HOUSE BILL 848
(II) EXCEPT WHERE A SHORT ER TIME PERIOD IS OT HERWISE 1
REQUIRED UNDER THIS TITLE, RESPOND TO VOICEMAIL S OR E–MAILS WITHIN 2 2
BUSINESS DAYS AFTER RECEIPT OF THE VOICE MAIL OR E–MAIL. 3
(2) THE PHONE TELEPHONE NUMBER AND E –MAIL ADDRESS SHALL 4
BE PROMINENTLY DISPL AYED ON THE NOTICES REQUIRED UNDER § 15–10A–02(F) 5
AND (I) OF THIS TITLE. 6
SECTION 2. 3. AND BE IT FURTHER ENACTED, That Section 2 of this Act shall 7
take effect October 1, 2025. 8
SECTION 4. AND BE IT FURTHER ENACTED, That, except as provided in Section 9
3 of this Act, this Act shall take effect June 1, 2025. 10
Approved:
________________________________________________________________________________
Governor.
________________________________________________________________________________
Speaker of the House of Delegates.
________________________________________________________________________________
President of the Senate.