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*hb1376*
HOUSE BILL 1376
J5, J1, J4 (6lr3433)
ENROLLED BILL
— Health/Finance —
Introduced by Delegate Rosenberg Delegates Rosenberg, Alston, Bagnall, Cullison,
Guzzone, Hill, Hutchinson, Kaufman, Kipke, Lopez, Martinez, M. Morgan,
Reilly, Ross, Szeliga, White Holland, 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
Maryland Medical Assistance Program, Maryland Children’s Health Program, 2
and Health Insurance – Transfers to Special Pediatric Hospitals – Requirements 3
FOR the purpose of requiring the Maryland Medical Assistance Program , and the 4
Maryland Children’s Health Program , managed care organizations, and certain 5
health insurers, nonprofit health service plans, and health maintenance 6
organizations to provide a prior authorization determination regarding a transfer on 7
request of a special pediatric hospital or referring health care provider, to provide a 8
retrospective review of a determination of medical necessity under certain 9
circumstances, and to reimburse a special pediatric hospital or a referring health 10
care provider for administra tive days at the applicable rate for a certain period 11
within a certain number of business days; requiring the Maryland Department of 12
Health to adopt regulations, on or before a certain date, establishing a retrospective 13
2 HOUSE BILL 1376
review process for special pediatric hospitals; and generally relating to transfers to 1
special pediatric hospitals. 2
BY repealing and reenacting, without amendments, 3
Article – Health – General 4
Section 15–101(a) and (k), 15–102.3(m), and 15–103(a)(1) and (2)(xxvi) 5
Annotated Code of Maryland 6
(2023 Replacement Volume and 2025 Supplement) 7
BY repealing 8
Article – Health – General 9
Section 15–102.3(m) 10
Annotated Code of Maryland 11
(2023 Replacement Volume and 2025 Supplement) 12
BY repealing and reenacting, with amendments, 13
Article – Health – General 14
Section 15–102.3(n) and (o), 15–103(a)(2)(xxvi), and 15–158 15
Annotated Code of Maryland 16
(2023 Replacement Volume and 2025 Supplement) 17
BY repealing and reenacting, with amendments, 18
Article – Insurance 19
Section 15–861 20
Annotated Code of Maryland 21
(2017 Replacement Volume and 2025 Supplement) 22
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 23
That the Laws of Maryland read as follows: 24
Article – Health – General 25
15–101. 26
(a) In this title the following words have the meanings indicated. 27
(k) “Special pediatric hospital” means a facility in the State that provides 28
nonacute medical, rehabilitation, therapy, and palliative services to individuals: 29
(1) Under the age of 22 years; or 30
(2) Who are at least 2 years old and under the age of 23 years and have 31
co–occurring physical and behavioral health conditions. 32
15–102.3. 33
HOUSE BILL 1376 3
(m) Beginning January 1, 2026, the provisions of § 15–861 of the Insurance Article 1
apply to managed care organizations in the same manner that they apply to carriers. 2
[(n)] (M) Beginning January 1, 2026, the provisions of § 15–862 of the Insurance 3
Article apply to managed care organizations in the same manner that they apply to carriers. 4
[(o)] (N) The provisions of § 15–863 of the Insurance Article apply to managed 5
care organizations in the same manner they apply to carriers. 6
15–103. 7
(a) (1) The Secretary shall administer the Maryland Medical Assistance 8
Program. 9
(2) The Program: 10
(xxvi) Beginning on January 1, 2026, shall provide coverage for a 11
transfer to a special pediatric hospital in accordance with § 15–861 of the Insurance Article 12
§ 15–158 OF THIS SUBTITLE; 13
15–158. 14
(A) (1) [The] SUBJECT TO PARAGRAPH (2) OF THIS SUBSECTION , THE 15
Program and the Maryland Children’s Health Program may not require prior authorization 16
for a transfer to a special pediatric hospital. 17
(2) AT THE REQUEST OF A S PECIAL PEDIATRIC HOS PITAL, THE 18
PROGRAM AND THE MARYLAND CHILDREN’S HEALTH PROGRAM SHALL PROVIDE A 19
PRIOR AUTHORIZATION DETERMINATION REGARDING A TRANSFER TO A SPECIAL 20
PEDIATRIC HOSPITAL W ITHIN 2 3 BUSINESS DAYS AFTER THE REQUEST IS 21
RECEIVED. 22
(B) (1) ON OR BEFORE DECEMBER 31, 2026, THE DEPARTMENT SHALL 23
ADOPT REGULATIONS ES TABLISHING A RETROSP ECTIVE REVIEW PROCES S FOR 24
SPECIAL PEDIATRIC HOSPITALS. 25
(2) THE REGULATIONS ADOPT ED UNDER PARAGRAPH (1) OF THIS 26
SUBSECTION SHALL: 27
(I) PROVIDE FOR A PEER –TO–PEER RECONSIDERATION OF A 28
MEDICAL NECESSITY DE TERMINATION MADE BY THE DEPARTMENT OR ITS AGE NT 29
ON REQUEST OF A PEDIATRIC SPECIALTY HOSPITAL; 30
(II) PROVIDE FOR RETROSPEC TIVE REVIEW OF ANY M EDICAL 31
NECESSITY DETERMINATION ISSUED BY THE DEPARTMENT OR ITS AGENT DENYING: 32
4 HOUSE BILL 1376
1. ADMISSION TO A SPECIA L PEDIATRIC HOSPITAL ON 1
OR AFTER JULY JANUARY 1, 2025; OR 2
2. REIMBURSEMENT FOR INP ATIENT SERVICES OR 3
OUTPATIENT SERVICES PROVIDED BY A SPECIAL PEDIATRIC HOSPITAL ON OR AFTER 4
JULY JANUARY 1, 2025; 5
(III) COMPLY WITH TITLE 10, SUBTITLE 2 OF THE STATE 6
GOVERNMENT ARTICLE; AND 7
(IV) PROVIDE THAT THE RETR OSPECTIVE REVIEW PROCESS BE 8
CONDUCTED BY A LICENSED PHYSICIAN. 9
(A) (1) IN THIS SECTION THE F OLLOWING WORDS HAVE THE MEANINGS 10
INDICATED. 11
(2) “ADMINISTRATIVE DAY” MEANS A DAY DURING WHICH A HEALTH 12
CARE PROVIDER DELIVERS CARE TO A PATIENT WHO NO LONGER REQUIR ES CARE 13
FROM THE PROVIDER BU T WHO THE PROVIDER I S UNABLE TO DISCHARG E OR 14
TRANSFER TO ANOTHER CARE SETTING. 15
(3) “MEDICALLY NECESSARY” MEANS THAT CARE IS: 16
(I) DIRECTLY RELATED TO D IAGNOSTIC, PREVENTIVE, 17
CURATIVE, PALLIATIVE, REHABILITATIVE, OR AMELIORATIVE TREA TMENT OF AN 18
ILLNESS, AN INJURY, A DISABILITY, OR ANY HEALTH CONDITION; 19
(II) CONSISTENT WITH ACCEP TED STANDAR DS OF GOOD 20
MEDICAL PRACTICE; AND 21
(III) NOT PRIMARILY FOR THE CONVENIENCE OF THE P ATIENT, 22
THE PATIENT’S FAMILY, OR THE PROVIDER. 23
(B) The Program and the Maryland Children’s Health Program [may]: 24
(1) MAY not require prior authorization for a transfer to a special pediatric 25
hospital; BUT 26
(2) SUBJECT TO SUBSECTION (C) OF THIS SECTION, SHALL PROVIDE 27
A PRIOR AUTHORIZATIO N DETERMINATION FOR A TRANSFER TO A SPEC IAL 28
PEDIATRIC HOSPITAL ON REQUEST OF THE SPECIAL PEDIATRIC HOSPITAL OR THE 29
REFERRING HEALTH CARE PROVIDER. 30
HOUSE BILL 1376 5
(C) IF THE PROGRAM OR MARYLAND CHILDREN’S HEALTH PROGRAM 1
RECEIVE A REQUEST UN DER SUBSECTION (B)(2) OF THIS SECTION, THE PROGRAM 2
OR MARYLAND CHILDREN’S HEALTH PROGRAM SHALL PROVIDE THE PRIO R 3
AUTHORIZATION DETERMINATION WITHIN 3 BUSINESS DAYS AFTER THE REQUEST IS 4
RECEIVED. 5
(D) (1) (I) IF A SPECIAL PEDIATRI C HOSPITAL OR A REFE RRING 6
HEALTH CARE PROVIDER DISAGREES WITH A DETERMINATION BY THE PROGRAM OR 7
MARYLAND’S CHILDREN HEALTH PROGRAM THAT A TRANSFER TO A SPECIA L 8
PEDIATRIC HOSPITAL I S NOT MEDICALLY NECE SSARY, THE SPECIAL PEDIATRI C 9
HOSPITAL OR THE REFE RRING HEALTH CARE PR OVIDER MAY REQUEST A 10
RETROSPECTIVE REVIEW BY THE PROGRAM OR MARYLAND CHILDREN’S HEALTH 11
PROGRAM IN ACCORDANCE WITH TITLE 10, SUBTITLE 2 OF THE STATE 12
GOVERNMENT ARTICLE. 13
(II) THE PROGRAM OR MARYLAND CHILDREN’S HEALTH 14
PROGRAM SHALL CONDUCT A REQUESTED RETROSPE CTIVE REVIEW EVEN IF THE 15
ENROLLEE WILL NOT BENEFIT FINANCIALLY FROM THE OUTCOME OF THE APPEAL. 16
(2) IF A SPECIAL PEDI ATRIC HOSPITAL OR A REFERRING HEALTH 17
CARE PROVIDER REQUESTS A RETROSPECTIVE REVIEW UNDER PARAGRAPH (1) OF 18
THIS SUBSECTION, THE SPECIAL PEDIATRIC HOSPITAL OR THE REFERRING HEALTH 19
CARE PROVIDER SHALL BE REIMBURSED FOR AL L ADMINISTRATIVE DAY S AT THE 20
APPLICABLE RATE FROM THE DATE OF THE MEDICAL NECES SITY DETERMINATION 21
UNTIL THE CONCLUSION OF THE RETROSPECTIVE REVIEW. 22
Article – Insurance 23
15–861. 24
(a) (1) In this section [, “special ] THE FOLLOWING WORDS HAVE THE 25
MEANINGS INDICATED. 26
(2) “ADMINISTRATIVE DAY” HAS THE MEANING STAT ED IN § 15–158 27
OF THE HEALTH – GENERAL ARTICLE. 28
(3) “MEDICALLY NECESSARY” HAS THE MEANING STATED IN § 15–158 29
OF THE HEALTH – GENERAL ARTICLE. 30
(4) “SPECIAL pediatric hospital” has the meaning stated in § 15 –101 of 31
the Health – General Article. 32
(b) This section applies to: 33
6 HOUSE BILL 1376
(1) insurers and nonprofit health service plans that provide hospital, 1
medical, or surgical benefits to individuals or groups on an expense –incurred basis under 2
health insurance policies or contracts that are issued or delivered in the State; and 3
(2) health maintenance organizations that provide hospital, medical, or 4
surgical benefits to individuals or groups under contracts that are issued or delivered in 5
the State. 6
(c) An entity subject to this section: 7
(1) may not require prior authorization for a transfer to a special pediatric 8
hospital; BUT 9
(2) SUBJECT TO SUBSECTION (D) OF THIS SECTION, SHALL PROVIDE 10
A PRIOR AUTHORIZATIO N DETERMINATION FOR A TRANSFER TO A SPEC IAL 11
PEDIATRIC HOSPITAL O N REQUEST OF A SPECIAL PEDIATRIC HOSPITAL OR A 12
REFERRING HEALTH CARE PROVIDER. 13
(D) IF AN ENTITY SUBJECT TO THIS SECTION RECEIVES A REQUEST UNDER 14
SUBSECTION (C)(2) OF THIS SECTION , THE ENTITY SHALL PRO VIDE THE PRIOR 15
AUTHORIZATION DETERMINATION WITHIN 3 BUSINESS DAYS AFTER THE REQUEST IS 16
RECEIVED. 17
(E) (1) IF A SPECIAL PEDIATRI C HOSPITAL OR A REFE RRING HEALTH 18
CARE PROVIDER DISAGR EES WITH A DETERMINA TION BY THE ENTITY T HAT A 19
TRANSFER TO A SPECIAL PEDIATRIC HOSPITAL IS NOT MEDICALLY NECESSARY, THE 20
SPECIAL PEDIATRIC HO SPITAL OR THE REFERRING HEALTH CARE PROVIDER MAY 21
REQUEST A RETROSPECT IVE REVIEW BY THE EN TITY THAT MADE THE 22
DETERMINATION. 23
(2) THE ENTITY THAT IS RE QUESTED TO CONDUCT T HE 24
RETROSPECTIVE REVIEW SHALL CONDUCT THE REVIEW EVEN IF THE INSURED WILL 25
NOT BENEFIT FINANCIALLY FROM THE OUTCOME OF THE APPEAL. 26
(3) IF A SPECIAL PEDIATRI C HOSPITAL OR A REFE RRING HEALTH 27
CARE PROVIDER REQUESTS A RETROSPECTIVE REVIEW UNDER PARAGRAPH (1) OF 28
THIS SUBSECTION, THE SPECIAL PEDIATRIC HOSPITAL OR THE REFERRING HEALTH 29
CARE PROVIDER SHALL BE REIMBURSE D FOR ALL ADMINISTRA TIVE DAYS AT THE 30
APPLICABLE RATE FROM THE DATE OF THE MEDI CAL NECESSITY DETERMINATION 31
UNTIL THE CONCLUSION OF THE RETROSPECTIVE REVIEW. 32
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 33
policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 34
after January 1, 2027. 35
HOUSE BILL 1376 7
SECTION 3. 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 1
January 1, 2027 July 1, 2026. 2
Approved:
________________________________________________________________________________
Governor.
________________________________________________________________________________
Speaker of the House of Delegates.
________________________________________________________________________________
President of the Senate.