Maryland Insurance Section 15-830

      (a)      (1)      In this section the following words have the meanings indicated.

            (2)      "Carrier" means:

                  (i)      an insurer that offers health insurance other than long-term care insurance or disability insurance;

                  (ii)      a nonprofit health service plan;

                  (iii)      a health maintenance organization;

                  (iv)      a dental plan organization; or

                  (v)      except for a managed care organization as defined in Title 15, Subtitle 1 of the Health - General Article, any other person that provides health benefit plans subject to State regulation.

            (3)      (i)      "Member" means an individual entitled to health care benefits under a policy or plan issued or delivered in the State by a carrier.

                  (ii)      "Member" includes a subscriber.

            (4)      "Provider panel" means those providers with which a carrier contracts to provide services to its members.

            (5)      "Specialist" means a physician who is certified or trained to practice in a specified field of medicine and who is not designated as a primary care provider by the carrier.

      (b)      (1)      Each carrier that does not allow direct access to specialists shall establish and implement a procedure by which a member may receive a standing referral to a specialist in accordance with this subsection.

            (2)      The procedure shall provide for a standing referral to a specialist if:

                  (i)      the primary care physician of the member determines, in consultation with the specialist, that the member needs continuing care from the specialist;

                  (ii)      the member has a condition or disease that:

                        1.      is life threatening, degenerative, chronic, or disabling; and

                        2.      requires specialized medical care; and

                  (iii)      the specialist:

                        1.      has expertise in treating the life-threatening, degenerative, chronic, or disabling disease or condition; and

                        2.      is part of the carrier's provider panel.

            (3)      Except as provided in subsection (c) of this section, a standing referral shall be made in accordance with a written treatment plan for a covered service developed by:

                  (i)      the primary care physician;

                  (ii)      the specialist; and

                  (iii)      the member.

            (4)      A treatment plan may:

                  (i)      limit the number of visits to the specialist;

                  (ii)      limit the period of time in which visits to the specialist are authorized; and

                  (iii)      require the specialist to communicate regularly with the primary care physician regarding the treatment and health status of the member.

            (5)      The procedure by which a member may receive a standing referral to a specialist may not include a requirement that a member see a provider in addition to the primary care physician before the standing referral is granted.

      (c)      (1)      Notwithstanding any other provision of this section, a member who is pregnant shall receive a standing referral to an obstetrician in accordance with this subsection.

            (2)      After the member who is pregnant receives a standing referral to an obstetrician, the obstetrician is responsible for the primary management of the member's pregnancy, including the issuance of referrals in accordance with the carrier's policies and procedures, through the postpartum period.

            (3)      A written treatment plan may not be required when a standing referral is to an obstetrician under this subsection.

      (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;

                  (ii)      the carrier does not have in its provider panel a specialist with the professional training and expertise to treat the condition or disease; 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)      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)      Each carrier shall file with the Commissioner a copy of each of the procedures required under this section.