Md. Code Regs. 31.10.51.04

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

Section 31.10.51.04 - Filing of Nonquantitative Treatment Limitation Comparative Analysis Report

A. For the five health benefit plans with the highest enrollment for each product offered by the carrier in the individual, small, and large group markets, a carrier that delivers or issues for delivery a health benefit plan in the State shall file a comparative analysis for each nonquantitative treatment limitation specified in the form required by the Commissioner, to demonstrate the carrier's compliance with Insurance Article, § 15-144(c) - (e), Annotated Code of Maryland. An analysis report shall be filed with the Commissioner using only the form developed by the Commissioner and posted on the Administration's website.

B. Carriers shall prepare the analysis report in coordination with any entity the carrier contracts with to provide, manage, or administer MH/SUD benefits.

C. Carriers shall follow the instructions posted on the Administration's website to complete the analysis report.

D. A complete analysis report shall include responses to each section of the standardized form, as described in the instructions posted on the Administration's website.

E. Each analysis report shall contain a statement, signed by a corporate officer, attesting to the accuracy of the information contained in the analysis report.

F. Failure to file a complete analysis report shall result in penalties described in Insurance Article, § 15-144(j), Annotated Code of Maryland.

G. Complete Analysis Report.

(1) The analysis required by Insurance Article, § 15-144(d), Annotated Code of Maryland, shall have been performed for processes in place during the calendar year preceding the analysis report.

(2) A carrier shall analyze each NQTL separately for each classification and sub-classification, as applicable, of benefits.

(3) If the carrier delegates administration or management of mental health, substance use disorder, or medical/surgical benefits to another entity (for example, a private review agent specializing in mental health and substance use disorder benefits or a pharmacy benefits manager), the analyses shall be conducted with close and coordinated involvement of both the carrier and the entity delegated by the carrier to manage mental health, substance use disorder, or medical/surgical benefits on behalf of the carrier. The carrier is responsible for providing all required information for the analyses, regardless of any delegation arrangement with a subcontracted entity.

(4) The analysis reports shall include the following information to be considered complete:

(a) All of the information identified in Insurance Article, § 15-144(e), Annotated Code of Maryland, in the manner and format specified in the standard reporting form and associated instructions provided on the Administration's website;

(b) A response to each step listed in the reporting form, for each NQTL in each classification and sub-classification, as applicable. If a particular item in a step is not applicable (for example, if none of the factors used to determine that the NQTL will apply to a benefit was given more weight than another), an explanation shall be provided as to why the item is not applicable;

(c) A statement as to whether there is any variation in the application of a guideline or standard used by the earner between MH/SUD and medical/surgical benefits, and, if so, a description of the factors and process used for establishing that variation. Specific definitions of factors, processes, or criteria used to establish or support any variation is required. Any practice guidelines that may be associated with the NQTL shall also be provided;

(d) If the application of the NQTL turns on specific decisions in the administration of the benefits, identification of the basis of the decisions, the decision maker or makers, the timing of the decisions, and the qualifications of the decision maker or makers, including expertise and specialty;

(e) If the analyses rely upon any experts, an assessment of each expert's qualifications, expertise and specialty, and a description of the extent to which the carrier relied upon each expert's evaluations in setting recommendations regarding both MH/SUD and medical/surgical benefits. Any variation in the use of experts (for example, specialty matching, licensure levels, etc.) for MH/SUD compared to M/S shall be defined and justified;

(f) A description of all exception processes available for each NQTL and when the exception may be applied;

(g) An explanation of how much discretion is allowed in applying the NQTL and whether such discretion is afforded comparably for processing MH/SUD benefit claims and medical/surgical benefits claims;

(h) Documentation of audits, reviews, and analyses to check sample claims or other administrative data to assess how each NQTL operates in practice, and whether written processes are correctly carried out, including the results of the audits and reviews performed on the NQTLs identified in Insurance Article, § 15-144(c)(2)(H), Annotated Code of Maryland, to conduct the comparative analysis required under Insurance Article, § 15-144(d)(2), Annotated Code of Maryland, as written, and in operation;

(i) Citations to any documents, studies, testing, claims data, or reports that include factors, sources, evidentiary standards, or other evidence relied upon in developing the NQTL (for example, meeting minutes or reports showing how those considerations were applied), with copies of those items available on request; and

(j) A description of the consequences or penalties that apply when the NQTL requirement is not met.

Md. Code Regs. 31.10.51.04

Regulations .04 adopted effective 48:26 Md. 1113, eff. 12/27/2021