Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 4
Subtitle 25 - MARYLAND HEALTH CARE COMMISSION
Chapter 10.25.17 - Benchmarks for Preauthorization of Health Care Services
Section 10.25.17.05 - Waiver from Benchmark Requirement

Universal Citation: MD Code Reg 10.25.17.05

Current through Register Vol. 51, No. 19, September 20, 2024

A. A payor may request that the Commission issue or renew a waiver from the requirement to meet a benchmark in Regulation .03 of this chapter by the demonstration of the following extenuating circumstances:

(1) For an insurer or nonprofit health service plan, a premium volume that is less than $1,000,000 annually in the State;

(2) For a group model health maintenance organization, as defined in Health-General Article, §19-713.6, Annotated Code of Maryland, preauthorizations of health care services requested by providers not employed by the group model health maintenance organization; or

(3) Other circumstances determined by the Executive Director to be extenuating.

B. Submission of Request for Waiver or Renewal of Waiver.

(1) A request for a waiver or renewal of waiver shall be in writing and shall include:
(a) An identification of each preauthorization benchmark for which a waiver is requested; and

(b) A detailed explanation of the extenuating circumstances necessitating the waiver.

(2) A request for a waiver shall be filed with the Commission in accordance with the following:
(a) For renewal of a waiver, no later than 30 days prior to its expiration; or

(b) For a payor that becomes authorized to provide benefits or services within the State of Maryland after October 1, 2012, within 3 months after the date the payor is authorized to provide benefits or services within the State.

C. Issuance of Waiver.

(1) The Executive Director may issue a waiver from a preauthorization benchmark to a payor that demonstrates extenuating circumstances within this chapter.

(2) The Executive Director will review and provide a decision to approve or deny all waiver requests within a reasonable time frame.

(3) A waiver or renewal of a waiver shall be valid for 2 years, unless withdrawn by the Executive Director.

D. Withdrawal of Waiver.

(1) The Executive Director may withdraw a waiver or renewal of a waiver if the Executive Director determines that the payor can no longer demonstrate extenuating circumstances.

(2) If the Executive Director withdraws a waiver or renewal of waiver, the Executive Director shall notify the payor, setting forth in writing the reasons for withdrawal.

(3) After a waiver or a renewal of a waiver is withdrawn, a payor shall submit a plan to the Executive Director within 30 days that includes a timeline for attaining each benchmark in Regulation .03 of this chapter in a format approved by the Commission.

E. Review of Denial or Withdrawal of Waiver.

(1) If the Executive Director has denied or withdrawn a waiver, a payor may seek Commission review of the denial or withdrawal by filing a written request for review with the Commission within 20 days of receipt of the Executive Director's notice of denial or withdrawal of a waiver, which shall:
(a) State with particularity the grounds and factual basis for a payor's disagreement with the denial or withdrawal decision;

(b) Specify the remedy requested; and

(c) If desired, include a written request to orally address the Commission, which shall be scheduled if requested.

(2) The full Commission may review the written request for review of a denial or withdrawal of a waiver directly or, at the discretion of the Chair of the Commission, appoint a Commissioner to review the request submitted under §E(1) of this regulation, who will make a recommendation to the full Commission.

(3) If a written request was submitted under §E(1)(c) of this regulation, a payor may orally address the Commission before a determination is made by the Commission as to whether or not to issue or withdraw a waiver.

(4) After reviewing and considering a payor's written request for review of the denial or withdrawal decision and any oral argument, if applicable, the full Commission shall issue a written decision affirming, reversing, or modifying the decision reviewed.

F. A waiver or renewal of waiver from the requirements of this chapter may not be sold, assigned, leased, or transferred.

Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.