Network Adequacy Regulations

The final regulations, which appeared in the December 8 Maryland Register, became effective on December 31, 2017.

For an excellent issue brief on the regulations, click here.

The first reports by carriers were due July 1, 2018.

Referring Patients Out of Network when a Carrier’s Network Is Inadequate

According to MIA MHPEAEA Special Assistant Darci Smith, J.D. in August 2017,  some carriers approve members/insureds to access treatment from an out-of-network provider when it is determined that the carrier’s network is inadequate. This is not an automatic exception allowing members to access out-of-network providers without first contacting the carrier and requesting a referral. The insureds must follow the terms of their policies and contact their insurance company and receive approval before accessing an out-of-network provider to confirm that the out-of-network treatment will be covered and what the out of pocket cost sharing will be.

Maryland Insurance Article Section 15-830(d) requires that carriers have a process in place for referring members to out of network providers when the carrier’s network is inadequate. This provision also establishes how the insured’s out of pocket costs should be determined.

If an insured is denied a referral to an out-of-network provider where the out-of-network care is medically necessary because there is no in-network provider with the appropriate training available, or treatment by an in-network provider would require unreasonable travel or delay, the insured must appeal that denial in writing with the insurance company. If there is a compelling reason, the internal grievance process does not have to be exhausted.

The Heath Education and Advocacy Unit (“HEAU”) of the Maryland Attorney General’s Office is available to assist in preparing a grievance to file through the carrier’s internal grievance process or a complaint with the Insurance Administration. HEAU can be contacted by phone: 410-528-1840 or by email: If the appeal is not successful, the insured can file a written complaint with the Maryland Insurance Administration online at

Finally, the insured (or the provider on the insured’s behalf) may contact the MIA Life and Health Complaint Department (410-468-2244 or if the carrier fails to respond to the insured’s request for a referral.