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.
*sb0474*
SENATE BILL 474
J5 5lr3154
CF HB 848
By: Senator Beidle
Introduced and read first time: January 22, 2025
Assigned to: Finance
Committee Report: Favorable with amendments
Senate action: Adopted
Read second time: February 16, 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 certain carriers to provide 5
certain information to the Maryland Insurance Commissioner on adverse decisions 6
on types of services that have grown by more than certain percentages over certain 7
periods of time; authorizing the Commissioner to use certain adverse decision 8
information as the basis of a certain examination; and generally relating to health 9
insurance and adverse decisions. 10
BY repealing and reenacting, without amendments, 11
Article – Insurance 12
Section 15–10A–02(a) 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) and 15–10A–06 18
Annotated Code of Maryland 19
(2017 Replacement Volume and 2024 Supplement) 20
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 21
That the Laws of Maryland read as follows: 22 2 SENATE BILL 474
Article – Insurance 1
15–10A–02. 2
(a) Each carrier shall establish an internal grievance process for its members. 3
(f) (1) For nonemergency cases, when a carrier renders an adverse decision, 4
the carrier shall: 5
(i) inform the member, the member’s representative, or the health 6
care provider acting on behalf of the member of the adverse decision: 7
1. orally by telephone; or 8
2. with the affirmative consent of the member, the member’s 9
representative, or the health care provider acting on behalf of the member, by text, 10
facsimile, e–mail, an online portal, or other expedited means; and 11
(ii) send, within 5 working days after the adverse decision has been 12
made, a written notice to the member, the member’s representative, and a health care 13
provider acting on behalf of the member that: 14
1. states in detail in clear, understandable language the 15
specific factual bases for the carrier’s decision and the reasoning used to determine that the 16
health care service is not medically necessary and did not meet the carrier’s criteria and 17
standards used in conducting the utilization review; 18
2. provides the specific reference, language, or requirements 19
from the criteria and standards, including any interpretive guidelines, on which the 20
decision was based, and may not solely use: 21
A. generalized terms such as “experimental procedure not 22
covered”, “cosmetic procedure not covered”, “service included under another procedure”, or 23
“not medically necessary”; or 24
B. language directing the member to review the additional 25
coverage criteria in the member’s policy or plan documents; 26
3. [states the name,] INCLUDES A UNIQUE ID ENTIFIER 27
FOR AND THE business address[,] and business telephone number of: 28
A. if the carrier is a health maintenance organization, the 29
medical director or associate medical director, as appropriate, who made the decision; or 30
B. if the carrier is not a health maintenance organization, the 31
designated employee or representative of the carrier who has responsibility for the carrier’s 32 SENATE BILL 474 3
internal grievance process and the physician who is required to make all adverse decisions 1
as required in § 15–10B–07(a) of this title; 2
4. gives written details of the carrier’s internal grievance 3
process and procedures under this subtitle; and 4
5. includes the following information: 5
A. that the member, the member’s representative, or a health 6
care provider on behalf of the member has a right to file a complaint with the Commissioner 7
within 4 months after receipt of a carrier’s grievance decision; 8
B. that a complaint may be filed without first filing a 9
grievance if the member, the member’s representative, or a health care provider filing a 10
grievance on behalf of the member can demonstrate a compelling reason to do so as 11
determined by the Commissioner; 12
C. the Commissioner’s address, telephone number, and 13
facsimile number; 14
D. a statement that the Health Advocacy Unit is available to 15
assist the member or the member’s representative in both mediating and filing a grievance 16
under the carrier’s internal grievance process; and 17
E. the address, telephone number, facsimile number, and 18
electronic mail address of the Health Advocacy Unit. 19
(2) The business telephone number included in the notice as required 20
under paragraph (1)(ii)3 of this subsection must be a dedicated number for adverse 21
decisions and may not be the general customer call number for the carrier. 22
(i) (1) For nonemergency cases, when a carrier renders a grievance decision, 23
the carrier shall: 24
(i) document the grievance decision in writing after the carrier has 25
provided oral communication of the decision to the member, the member’s representative, 26
or the health care provider acting on behalf of the member; and 27
(ii) send, within 5 working days after the grievance decision has been 28
made, a written notice to the member, the member’s representative, and a health care 29
provider acting on behalf of the member that: 30
1. states in detail in clear, understandable language the 31
specific factual bases for the carrier’s decision and the reasoning used to determine that the 32
health care service is not medically necessary and did not meet the carrier’s criteria and 33
standards used in conducting utilization review; 34
4 SENATE BILL 474
2. 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. [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. 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 of this subsection must be a dedicated number for grievance 25
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 SENATE BILL 474 5
(a) (1) On a quarterly basis, each carrier shall submit to the Commissioner, on 1
the form the Commissioner requires, a report that describes: 2
[(1)] (I) the number of members entitled to health care benefits under a 3
policy, plan, or certificate issued or delivered in the State by the carrier; 4
[(2)] (II) the number of clean claims for reimbursement processed by the 5
carrier; 6
[(3)] (III) the activities of the carrier under this subtitle, including: 7
[(i)] 1. the outcome of each grievance filed with the carrier; 8
[(ii)] 2. the number and outcomes of cases that were considered 9
emergency cases under § 15–10A–02(b)(2)(i) of this subtitle; 10
[(iii)] 3. the time within which the carrier made a grievance 11
decision on each emergency case; 12
[(iv)] 4. the time within which the carrier made a grievance 13
decision on all other cases that were not considered emergency cases; 14
[(v)] 5. the number of grievances filed with the carrier that 15
resulted from an adverse decision involving length of stay for inpatient hospitalization as 16
related to the medical procedure involved; 17
[(vi)] 6. the number of adverse decisions issued by the carrier 18
under § 15–10A–02(f) of this subtitle, whether the adverse decision involved a prior 19
authorization or step therapy protocol, and the type of service at issue in the adverse 20
decisions; 21
[(vii)] 7. the number of adverse decisions overturned after a 22
reconsideration request under § 15–10B–06 of this title; and 23
[(viii)] 8. the number of requests made and granted under § 24
15–831(c)(1) and (2) of this title; and 25
[(4)] (IV) the number and outcome of all other cases that are not subject to 26
activities of the carrier under this subtitle that resulted from an adverse decision involving 27
the length of stay for inpatient hospitalization as related to the medical procedure involved. 28
(2) IF THE NUMBER OF ADVE RSE DECISIONS ISSUED BY A CARRIER 29
FOR A TYPE OF SERVICE HA S GROWN BY MORE THAN 10% IN THE IMMEDIATELY 30
PRECEDING CALENDAR Y EAR OR 25% IN THE IMMEDIATELY P RECEDING 3 31 6 SENATE BILL 474
CALENDAR YEARS , THE CARRIER SHALL SU BMIT IN THE REPORT R EQUIRED UNDER 1
PARAGRAPH (1) OF THIS SUBSECTION : 2
(I) A DESCRIPTION OF ANY CHANGES IN MEDIC AL 3
MANAGEMENT CONTRIBUT ING TO THE RISE IN A DVERSE DECISIONS FOR THE TYPE 4
OF SERVICE; AND 5
(II) ANY OTHER KNOWN REAS ONS FOR THE INCREASE ; AND 6
(III) A DESCRIPTION OF THE CARRIER’S EFFORTS AND ACTION S 7
TAKEN TO DETERMINE T HE REASON FOR THE INCREASE . 8
(b) The Commissioner shall: 9
(1) compile an annual summary report based on the information provided: 10
(i) under subsection (a) of this section; and 11
(ii) by the Secretary under § 19–705.2(e) of the Health – General 12
Article; 13
(2) report any violations or actions taken under § 15–10B–11 of this title; 14
and 15
(3) provide copies of the summary report to the Governor and, subject to § 16
2–1257 of the State Government Article, to the General Assembly. 17
(C) THE COMMISSIONER MAY USE INFORMATION PROVIDED U NDER 18
SUBSECTION (A) OF THIS SECTION AS T HE BASIS FOR AN EXAM INATION UNDER 19
TITLE 2, SUBTITLE 2 OF THIS ARTICLE. 20
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 21
October 1, 2025. 22
Approved:
________________________________________________________________________________
Governor.
________________________________________________________________________________
President of the Senate.
________________________________________________________________________________
Speaker of the House of Delegates.