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Bill Summary · SB 902

SB 902 — Health Insurance: Access to Nonparticipating Providers — Referrals, Additional Assistance, and Coverage

Status: Approved by the Governor — Chapter 661 (2025)

Purpose

SB 902 strengthens and makes permanent prior 2022 protections that allow insured members to obtain referrals to specialists or nonphysician specialists who are not in a carrier’s network when appropriate. It adds specific protections for mental health and substance use disorder (SUD) care, requires carriers to provide additional assistance when network access is inadequate, limits prior authorization/utilization review in certain referral situations, and directs the Maryland Health Care Commission (MHCC) to set reimbursement rates for nonparticipating providers.

Key provisions

  • Referral procedure requirement: Every carrier (insurers, nonprofit health plans, HMOs, dental plan organizations, and other State‑regulated health benefit plan providers) must maintain a procedure allowing members to request referrals to specialists or nonphysician specialists who are not in the carrier’s provider panel when:
    • the member is diagnosed with, or seeking care for, a condition that requires specialized services; and
    • the carrier lacks an appropriately trained in‑network specialist or cannot provide reasonable access per regulatory appointment waiting time and travel distance standards (with special emphasis on standards for mental health and SUD services).
  • Mental health / SUD protections:
    • If a member cannot access mental health or SUD services through the referral process, the carrier must provide additional assistance to identify and arrange coverage with a nonparticipating specialist or nonphysician specialist.
    • Services obtained via these referrals must be treated for cost‑sharing purposes as if provided in‑network. Mental health and SUD services must be covered for the duration of the treatment plan at no greater cost to the covered individual than if provided in‑network.
  • Limits on prior authorization / utilization review:
    • Carriers may not require prior authorization for scheduling an appointment with, reimbursing, or continuing an established treatment plan with a referred nonparticipating specialist.
    • Where a carrier approves a referral, it may not impose utilization review requirements beyond those that would apply if the service were provided by an in‑network provider.
  • Definitions and scope:
    • “Nonphysician specialist” expanded to include entities licensed as behavioral health programs.
    • The referral procedure cannot substitute for maintaining network adequacy under existing law.
  • Reimbursement methodology:
    • MHCC must establish (by January 1, 2026) a reimbursement formula to determine payment rates for nonparticipating providers delivering covered mental health/SUD services via these referrals and must hold public meetings with carriers, providers, and consumers in developing the formula.
  • Documentation and oversight:
    • Carriers must document referral requests and make documentation available to the Insurance Commissioner on request.

Who is affected

  • Insured members covered by carriers regulated in Maryland (individual, group, and employer plans subject to State regulation).
  • Nonparticipating specialists and nonphysician specialists (including behavioral health programs) — may see increased patient access and reimbursement under the new rules.
  • Carriers must modify procedures and comply with documentation, assistance, and reimbursement-related requirements.
  • Maryland Health Care Commission and Maryland Insurance Administration (MIA) have administrative roles.

Effective dates and applicability

  • Repeal of the June 30, 2025 termination of Chapters 271 & 272 (making those provisions permanent): effective June 1, 2025 (per fiscal note).
  • Referral and related procedural provisions: take effect January 1, 2026 and apply to policies, contracts, and health benefit plans issued, delivered, or renewed in Maryland on or after that date.

Fiscal and other impacts

  • Fiscal note: No State fiscal effect in FY2025. Minimal special fund revenue increase to MIA in FY2026 from a $125 rate and form filing fee; any additional MIA workload expected to be handled within existing resources. No impact on the State Employee and Retiree Health and Welfare Benefits Program. Local government fiscal effects not anticipated to be material.
  • Small business impact: Potentially meaningful positive effect for small nonparticipating health care practices (including behavioral health programs) through increased patient referrals and reimbursement.
  • Administrative: MHCC must develop a reimbursement formula and convene stakeholders; carriers must update referral procedures and documentation systems.

Related legislation

  • Cross-filed/companions: HB 11, HB 1869.

Compiled from official sources — confirm details with the bill’s official record.

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