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S.B. 686 VETOES
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(d) (1) Each carrier shall establish and implement a procedure by which a
member may request a referral to a specialist who is not part of the carrier's provider
panel in accordance with this subsection.
(2) The procedure shall provide for a referral to a specialist who is not
part of the carrier's provider panel if:
(i) the member is diagnosed with a condition or disease that
requires specialized medical care; AND
(ii) 1. the carrier does not have in its provider panel a specialist
with the professional training and expertise to treat the condition or disease; OR
2. THE CARRIER CANNOT PROVIDE REASONABLE ACCESS TO
A SPECIALIST WITH THE PROFESSIONAL TRAINING AND EXPERTISE TO TREAT THE
CONDITION OR DISEASE WITHOUT UNREASONABLE DELAY OR TRAVEL [and
(iii) the specialist agrees to accept the same reimbursement as
would be provided to a specialist who is part of the carrier's provider panel].
(E) FOR PURPOSES OF CALCULATING ANY DEDUCTIBLE, COPAYMENT
AMOUNT, OR COINSURANCE PAYABLE BY THE MEMBER A CARRIER SHALL TREAT
SERVICES RECEIVED IN ACCORDANCE WITH SUBSECTION (D) OF THIS SECTION AS IF
THE SERVICE WAS PROVIDED BY A PROVIDER ON THE CARRIER'S PROVIDER PANEL.
[(e)] (F) A decision by a carrier not to provide access to or coverage of
treatment by a specialist in accordance with this section constitutes an adverse
decision as defined under Subtitle 10A of this title if the decision is based on a finding
that the proposed service is not medically necessary, appropriate, or efficient.
[(f)] (G) Each carrier shall file with the Commissioner a copy of each of the
procedures required under this section.
SECTION 2. AND BE IT FURTHER ENACTED, That:
(a) On or before January 1, 2007, the Maryland Insurance Administration, in
consultation with the Department of Health and Mental Hygiene's Office of Health
Care Quality and other interested and affected parties, shall adopt regulations to
implement the provisions of § 15-112(b)(1)(i)1 of the Insurance Article, as enacted by
Section 1 of this Act, with respect to insurers, nonprofit health service plans, and
dental plan organizations.
(b) In developing the regulations required under subsection (a) of this section,
the Administration shall take into consideration the standards and procedures
adopted by national accrediting organizations for preferred provider organizations
and the laws of other states.
(c) Each insurer, nonprofit health service plan, and dental plan organization
offering preferred provider organization benefit plans in the State shall comply with
the regulations on or before July 1, 2007.
SECTION 3. AND BE IT FURTHER ENACTED, That, on or before January 1,
2008, the Maryland Insurance Administration shall:
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