EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*sb0474*
SENATE BILL 474
J5 5lr3154
CF 5lr2020
By: Senator Beidle
Introduced and read first time: January 22, 2025
Assigned to: Finance
A BILL ENTITLED
AN ACT concerning 1
Health Insurance – Adverse Decisions – Reporting and Examinations 2
FOR the purpose of requiring certain carriers to provide certain information to the 3
Maryland Insurance Commissioner on adverse decisions on types of services that 4
have grown by more than certain percentages over certain periods of time; 5
authorizing the Commissioner to use certain adverse decision information as the 6
basis of a certain examination; and generally relating to health insurance and 7
adverse decisions. 8
BY repealing and reenacting, with amendments, 9
Article – Insurance 10
Section 15–10A–06 11
Annotated Code of Maryland 12
(2017 Replacement Volume and 2024 Supplement) 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
15–10A–06. 17
(a) (1) On a quarterly basis, each carrier shall submit to the Commissioner, on 18
the form the Commissioner requires, a report that describes: 19
[(1)] (I) the number of members entitled to health care benefits under a 20
policy, plan, or certificate issued or delivered in the State by the carrier; 21
[(2)] (II) the number of clean claims for reimbursement processed by the 22
carrier; 23 2 SENATE BILL 474
[(3)] (III) the activities of the carrier under this subtitle, including: 1
[(i)] 1. the outcome of each grievance filed with the carrier; 2
[(ii)] 2. the number and outcomes of cases that were considered 3
emergency cases under § 15–10A–02(b)(2)(i) of this subtitle; 4
[(iii)] 3. the time within which the carrier made a grievance 5
decision on each emergency case; 6
[(iv)] 4. the time within which the carrier made a grievance 7
decision on all other cases that were not considered emergency cases; 8
[(v)] 5. the number of grievances filed with the carrier that 9
resulted from an adverse decision involving length of stay for inpatient hospitalization as 10
related to the medical procedure involved; 11
[(vi)] 6. the number of adverse decisions issued by the carrier 12
under § 15–10A–02(f) of this subtitle, whether the adverse decision involved a prior 13
authorization or step therapy protocol, and the type of service at issue in the adverse 14
decisions; 15
[(vii)] 7. the number of adverse decisions overturned after a 16
reconsideration request under § 15–10B–06 of this title; and 17
[(viii)] 8. the number of requests made and granted under § 18
15–831(c)(1) and (2) of this title; and 19
[(4)] (IV) the number and outcome of all other cases that are not subject to 20
activities of the carrier under this subtitle that resulted from an adverse decision involving 21
the length of stay for inpatient hospitalization as related to the medical procedure involved. 22
(2) IF THE NUMBER OF ADVE RSE DECISIONS ISSUED BY A CARRIER 23
FOR A TYPE OF SERVIC E HAS GROWN BY MORE THAN 10% IN THE IMMEDIATELY 24
PRECEDING CALENDAR Y EAR OR 25% IN THE IMMEDIATELY PRECEDING 3 25
CALENDAR YEARS , THE CARRIER SHALL SU BMIT IN THE REPORT R EQUIRED UNDER 26
PARAGRAPH (1) OF THIS SUBSECTION : 27
(I) A DESCRIPTION OF ANY CHANGES IN MEDICAL 28
MANAGEMENT CONTRIBUT ING TO THE RISE IN A DVERSE DECISIONS FOR THE TYPE 29
OF SERVICE; AND 30
(II) ANY OTHER KNOWN REAS ONS FOR THE INCREASE . 31
SENATE BILL 474 3
(b) The Commissioner shall: 1
(1) compile an annual summary report based on the information provided: 2
(i) under subsection (a) of this section; and 3
(ii) by the Secretary under § 19–705.2(e) of the Health – General 4
Article; 5
(2) report any violations or actions taken under § 15–10B–11 of this title; 6
and 7
(3) provide copies of the summary report to the Governor and, subject to § 8
2–1257 of the State Government Article, to the General Assembly. 9
(C) THE COMMISSIONER MAY USE INFORMATION PROVIDED UNDER 10
SUBSECTION (A) OF THIS SECTION AS T HE BASIS FOR AN EXAM INATION UNDER 11
TITLE 2, SUBTITLE 2 OF THIS ARTICLE. 12
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 13
October 1, 2025. 14