§ 15-854.1
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/md/insurance/15-854-1A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
§15–854.1.
(1)In this section the following words have the meanings indicated.
(2)“Active course of treatment” means a course of treatment for which an insured is actively seeing a health care provider and following the course of treatment.
(3)“Course of treatment” means treatment that:
(i)is prescribed to treat or ordered for the treatment of an insured with a specific condition;
(ii)is outlined and agreed to by the insured and the health care provider before the treatment begins; and
(iii)may be part of a treatment plan.
(1)This section applies to:
(i)insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and
(ii)health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(2)An insurer, a nonprofit health service plan, or a health maintenance organization that contracts with a private review agent under Subtitle 10B of this title is subject to the requirements of this section.
(3)An insurer, a nonprofit health service plan, or a health maintenance organization that contracts with a third party to dispense medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction is subject to the requirements of this section.
(1)Notwithstanding § 15–854 of this subtitle as it applies to coverage for prescription drugs, an entity subject to this section shall approve a request for the prior authorization of a course of treatment, including for chronic conditions, rehabilitative services, substance use disorders, and mental health conditions, that is:
(i)for a period of time that is as long as necessary to avoid disruptions in care; and
(ii)determined in accordance with applicable coverage criteria, the insured’s medical history, and the health care provider’s recommendation.
(2)For new enrollees, an entity subject to this section may not disrupt or require reauthorization for an active course of treatment for covered services for at least 90 days after the date of enrollment.