Shown verbatim: the complete text as captured from the official PDF posted by the Maryland General Assembly, fetched 2026-09-25. Page and line markers are part of the official record; nothing is edited or removed. This is the chaptered version. The official bill page.
WES MOORE, Governor Ch. 325
Chapter 325
(House Bill 1376)
AN ACT concerning
Maryland Medical Assistance Program, Maryland Children’s Health Program,
and Health Insurance – Transfers to Special Pediatric Hospitals – Requirements
FOR the purpose of requiring the Maryland Medical Assistance Program, and the
Maryland Children’s Health Program, managed care organizations, and certain
health insurers, nonprofit health service plans, and health maintenance
organizations to provide a prior authorization determination regarding a transfer on
request of a special pediatric hospital or referring health care provider, to provide a
retrospective review of a determination of medical necessity under certain
circumstances, and to reimburse a special pediatric hospital or a referring health
care provider for administrative days at the applicable rate for a certain period
within a certain number of business days; requiring the Maryland Department of
Health to adopt regulations, on or before a certain date, establishing a retrospective
review process for special pediatric hospitals; and generally relating to transfers to
special pediatric hospitals.
BY repealing and reenacting, without amendments,
Article – Health – General
Section 15–101(a) and (k), 15–102.3(m), and 15–103(a)(1) and (2)(xxvi)
Annotated Code of Maryland
(2023 Replacement Volume and 2025 Supplement)
BY repealing
Article – Health – General
Section 15–102.3(m)
Annotated Code of Maryland
(2023 Replacement Volume and 2025 Supplement)
BY repealing and reenacting, with amendments,
Article – Health – General
Section 15–102.3(n) and (o), 15–103(a)(2)(xxvi), and 15–158
Annotated Code of Maryland
(2023 Replacement Volume and 2025 Supplement)
BY repealing and reenacting, with amendments,
Article – Insurance
Section 15–861
Annotated Code of Maryland
(2017 Replacement Volume and 2025 Supplement)
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Ch. 325 2026 LAWS OF MARYLAND
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND,
That the Laws of Maryland read as follows:
Article – Health – General
15–101.
(a) In this title the following words have the meanings indicated.
(k) “Special pediatric hospital” means a facility in the State that provides
nonacute medical, rehabilitation, therapy, and palliative services to individuals:
(1) Under the age of 22 years; or
(2) Who are at least 2 years old and under the age of 23 years and have
co–occurring physical and behavioral health conditions.
15–102.3.
(m) Beginning January 1, 2026, the provisions of § 15–861 of the Insurance Article
apply to managed care organizations in the same manner that they apply to carriers.
[(n)] (M) Beginning January 1, 2026, the provisions of § 15–862 of the Insurance
Article apply to managed care organizations in the same manner that they apply to carriers.
[(o)] (N) The provisions of § 15–863 of the Insurance Article apply to managed
care organizations in the same manner they apply to carriers.
15–103.
(a) (1) The Secretary shall administer the Maryland Medical Assistance
Program.
(2) The Program:
(xxvi) Beginning on January 1, 2026, shall provide coverage for a
transfer to a special pediatric hospital in accordance with § 15–861 of the Insurance Article
§ 15–158 OF THIS SUBTITLE;
15–158.
(A) (1) [The] SUBJECT TO PARAGRAPH (2) OF THIS SUBSECTION, THE
Program and the Maryland Children’s Health Program may not require prior authorization
for a transfer to a special pediatric hospital.
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WES MOORE, Governor Ch. 325
(2) AT THE REQUEST OF A SPECIAL PEDIATRIC HOSPITAL, THE
PROGRAM AND THE MARYLAND CHILDREN’S HEALTH PROGRAM SHALL PROVIDE A
PRIOR AUTHORIZATION DETERMINATION REGARDING A TRANSFER TO A SPECIAL
PEDIATRIC HOSPITAL WITHIN 2 3 BUSINESS DAYS AFTER THE REQUEST IS
RECEIVED.
(B) (1) ON OR BEFORE DECEMBER 31, 2026, THE DEPARTMENT SHALL
ADOPT REGULATIONS ESTABLISHING A RETROSPECTIVE REVIEW PROCESS FOR
SPECIAL PEDIATRIC HOSPITALS.
(2) THE REGULATIONS ADOPTED UNDER PARAGRAPH (1) OF THIS
SUBSECTION SHALL:
(I) PROVIDE FOR A PEER–TO–PEER RECONSIDERATION OF A
MEDICAL NECESSITY DETERMINATION MADE BY THE DEPARTMENT OR ITS AGENT
ON REQUEST OF A PEDIATRIC SPECIALTY HOSPITAL;
(II) PROVIDE FOR RETROSPECTIVE REVIEW OF ANY MEDICAL
NECESSITY DETERMINATION ISSUED BY THE DEPARTMENT OR ITS AGENT DENYING:
1. ADMISSION TO A SPECIAL PEDIATRIC HOSPITAL ON
OR AFTER JULY JANUARY 1, 2025; OR
2. REIMBURSEMENT FOR INPATIENT SERVICES OR
OUTPATIENT SERVICES PROVIDED BY A SPECIAL PEDIATRIC HOSPITAL ON OR AFTER
JULY JANUARY 1, 2025;
(III) COMPLY WITH TITLE 10, SUBTITLE 2 OF THE STATE
GOVERNMENT ARTICLE; AND
(IV) PROVIDE THAT THE RETROSPECTIVE REVIEW PROCESS BE
CONDUCTED BY A LICENSED PHYSICIAN.
(A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS
INDICATED.
(2) “ADMINISTRATIVE DAY” MEANS A DAY DURING WHICH A HEALTH
CARE PROVIDER DELIVERS CARE TO A PATIENT WHO NO LONGER REQUIRES CARE
FROM THE PROVIDER BUT WHO THE PROVIDER IS UNABLE TO DISCHARGE OR
TRANSFER TO ANOTHER CARE SETTING.
(3) “MEDICALLY NECESSARY” MEANS THAT CARE IS:
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Ch. 325 2026 LAWS OF MARYLAND
(I) DIRECTLY RELATED TO DIAGNOSTIC, PREVENTIVE,
CURATIVE, PALLIATIVE, REHABILITATIVE, OR AMELIORATIVE TREATMENT OF AN
ILLNESS, AN INJURY, A DISABILITY, OR ANY HEALTH CONDITION;
(II) CONSISTENT WITH ACCEPTED STANDARDS OF GOOD
MEDICAL PRACTICE; AND
(III) NOT PRIMARILY FOR THE CONVENIENCE OF THE PATIENT,
THE PATIENT’S FAMILY, OR THE PROVIDER.
(B) The Program and the Maryland Children’s Health Program [may]:
(1) MAY not require prior authorization for a transfer to a special pediatric
hospital; BUT
(2) SUBJECT TO SUBSECTION (C) OF THIS SECTION, SHALL PROVIDE
A PRIOR AUTHORIZATION DETERMINATION FOR A TRANSFER TO A SPECIAL
PEDIATRIC HOSPITAL ON REQUEST OF THE SPECIAL PEDIATRIC HOSPITAL OR THE
REFERRING HEALTH CARE PROVIDER.
(C) IF THE PROGRAM OR MARYLAND CHILDREN’S HEALTH PROGRAM
RECEIVE A REQUEST UNDER SUBSECTION (B)(2) OF THIS SECTION, THE PROGRAM
OR MARYLAND CHILDREN’S HEALTH PROGRAM SHALL PROVIDE THE PRIOR
AUTHORIZATION DETERMINATION WITHIN 3 BUSINESS DAYS AFTER THE REQUEST IS
RECEIVED.
(D) (1) (I) IF A SPECIAL PEDIATRIC HOSPITAL OR A REFERRING
HEALTH CARE PROVIDER DISAGREES WITH A DETERMINATION BY THE PROGRAM OR
MARYLAND’S CHILDREN HEALTH PROGRAM THAT A TRANSFER TO A SPECIAL
PEDIATRIC HOSPITAL IS NOT MEDICALLY NECESSARY, THE SPECIAL PEDIATRIC
HOSPITAL OR THE REFERRING HEALTH CARE PROVIDER MAY REQUEST A
RETROSPECTIVE REVIEW BY THE PROGRAM OR MARYLAND CHILDREN’S HEALTH
PROGRAM IN ACCORDANCE WITH TITLE 10, SUBTITLE 2 OF THE STATE
GOVERNMENT ARTICLE.
(II) THE PROGRAM OR MARYLAND CHILDREN’S HEALTH
PROGRAM SHALL CONDUCT A REQUESTED RETROSPECTIVE REVIEW EVEN IF THE
ENROLLEE WILL NOT BENEFIT FINANCIALLY FROM THE OUTCOME OF THE APPEAL.
(2) IF A SPECIAL PEDIATRIC HOSPITAL OR A REFERRING HEALTH
CARE PROVIDER REQUESTS A RETROSPECTIVE REVIEW UNDER PARAGRAPH (1) OF
THIS SUBSECTION, THE SPECIAL PEDIATRIC HOSPITAL OR THE REFERRING HEALTH
CARE PROVIDER SHALL BE REIMBURSED FOR ALL ADMINISTRATIVE DAYS AT THE
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WES MOORE, Governor Ch. 325
APPLICABLE RATE FROM THE DATE OF THE MEDICAL NECESSITY DETERMINATION
UNTIL THE CONCLUSION OF THE RETROSPECTIVE REVIEW.
Article – Insurance
15–861.
(a) (1) In this section[, “special] THE FOLLOWING WORDS HAVE THE
MEANINGS INDICATED.
(2) “ADMINISTRATIVE DAY” HAS THE MEANING STATED IN § 15–158
OF THE HEALTH – GENERAL ARTICLE.
(3) “MEDICALLY NECESSARY” HAS THE MEANING STATED IN § 15–158
OF THE HEALTH – GENERAL ARTICLE.
(4) “SPECIAL pediatric hospital” has the meaning stated in § 15–101 of
the Health – General Article.
(b) This section applies to:
(1) insurers and nonprofit health service plans that provide hospital,
medical, or surgical benefits to individuals or groups on an expense–incurred basis under
health insurance policies or contracts that are issued or delivered in the State; and
(2) health maintenance organizations that provide hospital, medical, or
surgical benefits to individuals or groups under contracts that are issued or delivered in
the State.
(c) An entity subject to this section:
(1) may not require prior authorization for a transfer to a special pediatric
hospital; BUT
(2) SUBJECT TO SUBSECTION (D) OF THIS SECTION, SHALL PROVIDE
A PRIOR AUTHORIZATION DETERMINATION FOR A TRANSFER TO A SPECIAL
PEDIATRIC HOSPITAL ON REQUEST OF A SPECIAL PEDIATRIC HOSPITAL OR A
REFERRING HEALTH CARE PROVIDER.
(D) IF AN ENTITY SUBJECT TO THIS SECTION RECEIVES A REQUEST UNDER
SUBSECTION (C)(2) OF THIS SECTION, THE ENTITY SHALL PROVIDE THE PRIOR
AUTHORIZATION DETERMINATION WITHIN 3 BUSINESS DAYS AFTER THE REQUEST IS
RECEIVED.
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Ch. 325 2026 LAWS OF MARYLAND
(E) (1) IF A SPECIAL PEDIATRIC HOSPITAL OR A REFERRING HEALTH
CARE PROVIDER DISAGREES WITH A DETERMINATION BY THE ENTITY THAT A
TRANSFER TO A SPECIAL PEDIATRIC HOSPITAL IS NOT MEDICALLY NECESSARY, THE
SPECIAL PEDIATRIC HOSPITAL OR THE REFERRING HEALTH CARE PROVIDER MAY
REQUEST A RETROSPECTIVE REVIEW BY THE ENTITY THAT MADE THE
DETERMINATION.
(2) THE ENTITY THAT IS REQUESTED TO CONDUCT THE
RETROSPECTIVE REVIEW SHALL CONDUCT THE REVIEW EVEN IF THE INSURED WILL
NOT BENEFIT FINANCIALLY FROM THE OUTCOME OF THE APPEAL.
(3) IF A SPECIAL PEDIATRIC HOSPITAL OR A REFERRING HEALTH
CARE PROVIDER REQUESTS A RETROSPECTIVE REVIEW UNDER PARAGRAPH (1) OF
THIS SUBSECTION, THE SPECIAL PEDIATRIC HOSPITAL OR THE REFERRING HEALTH
CARE PROVIDER SHALL BE REIMBURSED FOR ALL ADMINISTRATIVE DAYS AT THE
APPLICABLE RATE FROM THE DATE OF THE MEDICAL NECESSITY DETERMINATION
UNTIL THE CONCLUSION OF THE RETROSPECTIVE REVIEW.
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all
policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or
after January 1, 2027.
SECTION 3. 2. AND BE IT FURTHER ENACTED, That this Act shall take effect
January 1, 2027 July 1, 2026.
Approved by the Governor, April 28, 2026.
–6–Every fact on this page links to its source, starting with the official bill record.