EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*sb0902*
SENATE BILL 902
J5, J4 5lr2854
CF HB 11
By: Senator Augustine
Introduced and read first time: January 28, 2025
Assigned to: Finance
A BILL ENTITLED
AN ACT concerning 1
Health Insurance – Access to Nonparticipating Providers – Referrals, Additional 2
Assistance, and Coverage 3
FOR the purpose of repealing the termination date for certain provisions of law related to 4
referrals to and reimbursement of specialists and nonphysician specialists who are 5
not part of a carrier’s provider panel; requiring that a certain referral procedure 6
required to be established and implemented by certain insurers, nonprofit health 7
service plans, and health maintenance organizations require the carrier to provide 8
certain assistance to a member in identifying and arranging coverage for a specialist 9
or nonphysician specialist for treatment of mental health or substance use disorder 10
services; prohibiting certain carriers from imposing prior authorization 11
requirements for scheduling, reimbursing, or continuing an established treatment 12
plan by certain nonparticipating providers; requiring the Maryland Health Care 13
Commission to establish certain reimbursement rates for nonparticipating 14
providers; and generally relating to access to nonparticipating providers. 15
BY repealing and reenacting, without amendments, 16
Article – Insurance 17
Section 15–830(a) 18
Annotated Code of Maryland 19
(2017 Replacement Volume and 2024 Supplement) 20
BY repealing and reenacting, with amendments, 21
Article – Insurance 22
Section 15–830(d) and (e) 23
Annotated Code of Maryland 24
(2017 Replacement Volume and 2024 Supplement) 25
BY repealing and reenacting, with amendments, 26
Chapter 271 of the Acts of the General Assembly of 2022 27
Section 4 28 2 SENATE BILL 902
BY repealing and reenacting, with amendments, 1
Chapter 272 of the Acts of the General Assembly of 2022 2
Section 4 3
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 4
That the Laws of Maryland read as follows: 5
Article – Insurance 6
15–830. 7
(a) (1) In this section the following words have the meanings indicated. 8
(2) “Carrier” means: 9
(i) an insurer that offers health insurance other than long–term 10
care insurance or disability insurance; 11
(ii) a nonprofit health service plan; 12
(iii) a health maintenance organization; 13
(iv) a dental plan organization; or 14
(v) except for a managed care organization as defined in Title 15, 15
Subtitle 1 of the Health – General Article, any other person that provides health benefit 16
plans subject to State regulation. 17
(3) (i) “Member” means an individual entitled to health care benefits 18
under a policy or plan issued or delivered in the State by a carrier. 19
(ii) “Member” includes a subscriber. 20
(4) “Nonphysician specialist” means a health care provider: 21
(i) 1. who is not a physician; 22
2. who is licensed or certified under the Health Occupations 23
Article; and 24
3. who is certified or trained to treat or provide health care 25
services for a specified condition or disease in a manner that is within the scope of the 26
license or certification of the health care provider; or 27
(ii) that is licensed as a behavioral health program under § 7.5–401 28
of the Health – General Article. 29 SENATE BILL 902 3
(5) (i) “Provider panel” means the providers that contract with a carrier 1
either directly or through a subcontracting entity to provide health care services to 2
enrollees of the carrier. 3
(ii) “Provider panel” does not include an arrangement in which any 4
provider may participate solely by contracting with the carrier to provide health care 5
services at a discounted fee–for–service rate. 6
(6) “Specialist” means a physician who is certified or trained to practice in 7
a specified field of medicine and who is not designated as a primary care provider by the 8
carrier. 9
(d) (1) Each carrier shall establish and implement a procedure by which a 10
member may request a referral to a specialist or nonphysician specialist who is not part of 11
the carrier’s provider panel in accordance with this subsection. 12
(2) The procedure shall provide for a referral to a specialist or nonphysician 13
specialist who is not part of the carrier’s provider panel if: 14
(i) the member is diagnosed with OR SEEKING CARE FOR a 15
condition or disease that requires specialized health care services or medical care; and 16
(ii) 1. the carrier does not have in its provider panel a specialist 17
or nonphysician specialist with the professional training and expertise to treat or provide 18
health care services for the condition or disease; or 19
2. the carrier cannot provide reasonable access to a specialist 20
or nonphysician specialist with the professional training and expertise to treat or provide 21
health care services for the condition or disease [without unreasonable delay or travel] 22
WITHIN THE REASONABL E APPOINTMENT WAITIN G TIME AND TRAVEL DI STANCE 23
STANDARDS ESTABLISHE D IN REGULATION . 24
(3) The procedure shall ensure that a request to obtain a referral to a 25
specialist or nonphysician specialist who is not part of the carrier’s provider panel is 26
addressed in a timely manner that is: 27
(i) appropriate for the member’s condition; and 28
(ii) in accordance with the timeliness requirements for 29
determinations made by private review agents under § 15–10B–06 of this title. 30
(4) IF A MEMBER CANNOT AC CESS MENTAL HEALTH OR SUBSTA NCE 31
USE DISORDER SERVICE S THROUGH THE REFERR AL REQUIREMENTS UNDE R 32
PARAGRAPHS (2) AND (3) OF THIS SUBSECTION , THE PROCEDURE SHALL REQUIRE 33
THE CARRIER TO PROVI DE ADDITIONAL ASSIST ANCE TO THE MEMBER I N 34 4 SENATE BILL 902
IDENTIFYING AND ARRA NGING COVERAGE OF MENTAL HEALTH OR SUB STANCE USE 1
DISORDER SERVICES BY A SPECIALIST OR NONP HYSICIAN SPECIALIST WHO IS NOT 2
PART OF THE CARRIER ’S PROVIDER PANEL . 3
(5) THE PROCEDURE MAY NOT REQUIRE PRIOR AUTHOR IZATION FOR 4
PURPOSES OF: 5
(I) SCHEDULING AN APPOIN TMENT WITH A SPECIALIST OR 6
NONPHYSICIAN SPECIAL IST WHO IS NOT PART OF THE CARRIER ’S PROVIDER PANEL ; 7
(II) REIMBURSING A SPECIA LIST OR NONPHYSICIAN SPECIALIST 8
WHO IS NOT PART OF T HE CARRIER’S PROVIDER PANEL ; OR 9
(III) CONTINUING AN ESTABL ISHED TREATMENT PLAN WITH A 10
SPECIALIST OR NONPHY SICIAN SPECIALIST WH O IS NOT PART OF THE CARRIER’S 11
PROVIDER PANEL . 12
[(4)] (6) The procedure may not be used by a carrier as a substitute for 13
establishing and maintaining a sufficient provider network in accordance with § 15–112 of 14
this title. 15
[(5)] (7) Each carrier shall: 16
(i) have a system in place that documents all requests to obtain a 17
referral to receive a covered service from a specialist or nonphysician specialist who is not 18
part of the carrier’s provider panel; 19
(ii) inform members of the procedure to request a referral under 20
paragraph (1) of this subsection; and 21
(iii) provide the information documented under item (i) of this 22
paragraph to the Commissioner on request. 23
(e) (1) Except as provided in paragraph (2) of this subsection, for purposes of 24
calculating any deductible, copayment amount, or coinsurance payable by the member, a 25
carrier shall treat services received in accordance with subsection (d) of this section as if 26
the service was provided by a provider on the carrier’s provider panel. 27
(2) A carrier shall ensure that services received in accordance with 28
subsection (d) of this section for mental health or substance use disorders are provided FOR 29
THE DURATION OF THE TREATMENT PLAN at no greater cost to the covered individual 30
than if the covered benefit were provided by a provider on the carrier’s provider panel. 31
(3) (I) SUBJECT TO SUBPARAGRA PH (II) OF THIS PARAGRAPH , AND 32
NOT LATER THAN JANUARY 1, 2026, THE MARYLAND HEALTH CARE COMMISSION 33 SENATE BILL 902 5
SHALL ESTABLISH A REIMBURSEMENT FORM ULA TO DETERMINE THE 1
REIMBURSEMENT RATE F OR NONPARTICIPATING PROVIDERS WHO DELIVE R 2
SERVICES UNDER PARAG RAPH (2) OF THIS SUBSECTION . 3
(II) THE MARYLAND HEALTH CARE COMMISSION SHALL HOLD 4
PUBLIC MEETINGS WITH CARRIERS, MENTAL HEALTH AN D SUBSTANCE USE 5
DISORDER PROVIDERS , CONSUMERS OF MENTAL HEALTH AND SUBSTANCE USE 6
DISORDER SERVICES , AND OTHER INTERESTED PARTIES TO DETERMINE THE 7
REIMBURSEMENT FORMUL A. 8
SECTION 2. AND BE IT FURTHER ENACTED, That the Laws of Maryland read 9
as follows: 10
Chapter 271 of the Acts of 2022 11
SECTION 4. AND BE IT FURTHER ENACTED, That this Act shall take effect July 12
1, 2022. [It shall remain effective for a period of 3 years and, at the end of June 30, 2025, 13
this Act, with no further action required by the General Assembly, shall be abrogated and 14
of no further force and effect.] 15
Chapter 272 of the Acts of 2022 16
SECTION 4. AND BE IT FURTHER ENACTED, That this Act shall take effect July 17
1, 2022. [It shall remain effective for a period of 3 years and, at the end of June 30, 2025, 18
this Act, with no further action required by the General Assembly, shall be abrogated and 19
of no further force and effect.] 20
SECTION 3. AND BE IT FURTHER ENACTED, That Section 1 of this Act shall 21
apply to all policies, contracts, and health benefit plans issued, delivered, or renewed in the 22
State on or after January 1, 2026. 23
SECTION 4. AND BE IT FURTHER ENACTED, That Section 1 of this Act shall take 24
effect January 1, 2026. 25
SECTION 5. AND BE IT FURTHER ENACTED, That, except as provided in Section 26
4 of this Act, this Act shall take effect June 1, 2025. 27