Bill > HB1153

This bill, concerning the Maryland Medical Assistance Program and health insurance, aims to prevent insurers, nonprofit health service plans, health maintenance organizations (HMOs), and managed care organizations (MCOs) from unfairly reducing payments for healthcare services by "downcoding" claims. Downcoding is defined as the unilateral alteration of a submitted service code by an insurer or its representative, resulting in a lower payment to the healthcare provider, without proper justification. The bill establishes specific procedures that these entities must follow if they intend to downcode a claim, including providing the healthcare provider with a notice within 30 days of receiving the claim, detailing the specific reasons for the downcoding, the original and revised codes with their corresponding payment amounts, and informing the provider of their right to respond with additional documentation within 90 days. Furthermore, any final decision to downcode a claim must be made by a physician board-certified or eligible in the same specialty as the service being reviewed and knowledgeable about the treatment. The bill also mandates that insurers report quarterly to the Commissioner on the number of claims they intend to downcode and the number of claims actually downcoded, and allows healthcare providers to file complaints directly with the Commissioner if a coverage decision is the result of a final downcoding determination, bypassing the usual internal appeal process. These provisions are intended to ensure fair reimbursement practices for healthcare providers and are set to take effect on October 1, 2026.

Health and Social Services

https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/HB1153?ys=2026RS