Md. Code Regs. 10.25.17.05

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.25.17.05 - Waiver from Benchmark Requirement

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(3) A waiver or renewal of a waiver shall be valid for 2 years, unless withdrawn by the Executive Director.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(3) After a waiver or a renewal of a waiver is withdrawn, a payor shall submit a plan to the Executive Director within 30 days that includes a timeline for attaining each benchmark in Regulation .03 of this chapter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.

Md. Code Regs. 10.25.17.05

Regulation .05 amended effective 42:20 Md. R. 1265, eff.10/12/2015; amended effective 49:27 Md. R. 1110, eff. 1/9/2023