During their 90-day legislative session, which concluded at midnight on April 8th, mental health and substance use disorder received significant attention from the Maryland General Assembly. The joint legislative committee of the Maryland Psychiatric Society (MPS) and the Washington Psychiatric Society (WPS) meticulously assessed sixty three (63) distinct pieces of legislation, excluding cross files, and actively advocated on forty three (43) bills. Below is a summary of the bills that successfully passed both chambers and are now under final consideration by the Governor.

 

Utilization Review

After 4 years of effort, we finally saw some movement on prior authorization. Senate Bill 791/House Bill 932, sponsored by Senator Kathy Klausmeier (D – Baltimore County) and Delegate Bonnie Cullison (D – Montgomery County) revise and establish requirements and limitations regarding health insurance utilization review and prior authorization processes, used to assess the medical necessity of requested health care services. These bills modify internal grievance and adverse decision procedures and impose obligations on payors and health care providers concerning patient benefit information provision. They introduce measures to enhance transparency and communication during the review phase. Carriers are obligated to provide detailed explanations for denying health care services, clarifying why they were deemed medically unnecessary and did not meet carrier criteria. Criteria and standards for utilization review are also adjusted, along with requirements for prescription drug reauthorization.

Online Prior Authorization Process: Carriers must implement and maintain an online prior authorization system meeting specified criteria by July 1, 2026. Additionally, by the same date, each carrier or their pharmacy benefits manager must furnish real-time patient-specific benefit information to insured individuals, enrollees, and contracted health care providers.

Prescription Drug Prior Authorizations: Upon receipt of prior authorization documentation from the insured or their health care provider, a carrier must honor a prior authorization granted by a previous entity for at least 90 days or the length of the treatment course, rather than just 30 days.

Prescription Drug Reauthorization Requirements: Carriers cannot issue adverse decisions on reauthorization for certain prescription drugs, nor request additional documentation from the prescriber under specific conditions, including continuous use of the drug since initial approval, and attestation by the prescriber of continued necessity based on professional judgment, particularly for immune globulin (human) or mental disorder treatments.

 

Assisted Outpatient Treatment

The Maryland Department of Health (MDH) introduced Senate Bill 453/House Bill 576 to establish Assisted Outpatient Treatment (AOT) programs aimed at providing specific outpatient treatment for individuals with serious and persistent mental illnesses who are court-ordered to adhere to the regimen. Under these programs, a multidisciplinary care coordination team, supervised by a local behavioral health authority or core service agency, oversees the development and implementation of treatment plans. These plans include crucial outpatient services deemed essential for maintaining the individual’s health and safety. Such services typically include those provided by a treating psychiatrist, case management, certified peer recovery specialists, and assertive community treatment services when clinically appropriate.

Counties are granted the authority to establish their own AOT programs, and they may choose to partner with other counties for this purpose. If a county opts not to establish such a program, the responsibility falls on MDH to establish one.

Petitions for AOT may be filed by the director of a mental health program receiving state funding or by any individual at least 18 years old who has a legitimate interest in the respondent’s welfare. These petitions must be supported by an affidavit from a psychiatrist affirming the respondent’s eligibility for AOT.

AOT may be ordered by the court if clear and convincing evidence demonstrates the respondent’s eligibility based on specific criteria. These criteria include the presence of a serious and persistent mental illness, a history of nonadherence to treatment leading to significant hospitalization or violent behavior, and the necessity of AOT to prevent harm to the individual or others. Throughout the process, respondents have the right to legal representation and may voluntarily agree to the treatment plan developed by the care coordination team. The team is responsible for ensuring that the treatment plan is recovery-oriented and consistent with evidence-based practices. The court oversees hearings where evidence, including testimony from psychiatrists, is presented. If ordered, the respondent must comply with the AOT plan, and failure to do so does not result in contempt of court.

Reports on AOT programs’ effectiveness and outcomes are to be submitted annually to the MGA. Counties must notify MDH of their intention to establish AOT programs by January 1, 2025, with the law taking effect on July 1, 2024, except for specific provisions effective July 1, 2025.

 

Parity Reporting

Senator Malcolm Augustine (D – Prince George’s County) and Delegate Heather Bagnall (D – Anne Arundel County) introduced Senate Bill 684/House Bill 1074 to amend and broaden reporting obligations for carriers to demonstrate adherence to the federal Mental Health Parity and Addiction Equity Act. Under the bill, each carrier is mandated to, among other provisions, (1) identify specific non-quantitative treatment limitations (NQTLs) for each Parity Act classification; (2) conduct and document specified comparative analyses as per the Parity Act; and (3) furnish the requisite comparative analysis for NQTLs within a stipulated timeframe set by the Commissioner.

Commencing July 1, 2024, each carrier must submit a biennial compliance report for every product offered across individual, small, and large group markets. This report must encompass designated details, including information on selected NQTLs and findings from carrier-conducted comparative analyses. Furthermore, the bills empower the Maryland Insurance Commissioner to take additional measures to ensure compliance with reporting mandates.

 

Conformity with Federal Law

At the request of the Maryland Insurance Administration, Senate Bill 217/House Bill 30 was passed to harmonize Maryland health insurance law and regulations with existing federal rules and regulations. These Acts modify definitions and coverage requirements concerning emergency services to align with consumer protection measures outlined in the federal No Surprises Act. Additionally, they adjust the criteria for special enrollment periods in the Small Business Health Options Program, and empower the Maryland Health Benefit Exchange to adopt an expanded open enrollment period and alternative effective dates of coverage, subject to approval by the U.S. Department of Health and Human Services. Moreover, the Acts mandate that regulations enacted by the Maryland Insurance Commissioner conform to federal regulations in effect as of December 1, 2023, updating the definition of “grandfather plan” accordingly.

The bill takes effect October 1, 2024.

 

Center for Firearm Violence Prevention

Senate Bill 475/House Bill 583, Moore administration bills, establish the Center for Firearm Violence Prevention and Intervention (CFVPI) within the Maryland Department of Health (MDH). The center’s aim is to curb firearm violence, minimize its impact, and address firearm misuse in the state by collaborating with federal, state, and local agencies and affected communities. CFVPI must consult specified state agencies and stakeholders, consider recommendations from designated communities and experts, and submit a preliminary State Plan for a Public Health Approach to Reducing Firearm Violence by May 1, 2025, followed by a State Strategic Plan for Firearm Violence Reduction Using Public Health Strategies by May 1, 2029, and every four years thereafter.

 

Commission on Behavioral Health Care Treatment and Access

Chapter 328 of 2015 established the Behavioral Health Advisory Council to advocate for improved behavioral health services statewide. Chapters 290 and 291 of 2023 set up the Commission on Behavioral Health Care Treatment and Access to ensure accessible and comprehensive services. Senate Bill 212/House Bill 1048 (Chs. 41 and 42 respectively), requested by the MDH, mandate collaboration between the council and the commission, including joint annual reports and at least three joint meetings per year. These acts also adjust council and commission memberships and require the commission to recommend Medicaid integration of somatic and behavioral health services.

The bill becomes effective July 1, 2024.

 

Language Assistance Services Pilot Program

Senate Bill 991 establishes the Language Assistance Services Pilot Program to provide meaningful access to behavioral health care to children with limited English proficiency and establish a competitive grant process for local behavioral health authorities to provide reimbursement to behavioral health providers for language assistance services.

The bill, sponsored by Senator Clarence Lam (D – Anne Arundel & Howard Counties), becomes effective July 1, 2024.

 

Opioid Restitution Advisory Council and Fund

Chapter 537 of 2019 established the Opioid Restitution Fund (ORF), a dedicated fund for revenues resulting from certain opioid judgments or settlements. These funds are exclusively designated for opioid-related programs and services. Chapter 270 of 2022 then formed the Opioid Restitution Fund Advisory Council to advise the Governor and the Secretary of Health on ORF allocation. Senate Bill 751/House Bill 980, sponsored by Senator Kathy Klausmeier (D – Baltimore County) and Delegate Sandy Rosenberg (D – Baltimore City) mandate the Secretary to present allocation decisions to the council within six months of receiving its recommendations. MDH is required to publish the council’s findings and recommendations along with the Secretary’s decisions on its website. Furthermore, ORF usage is expanded to support community-based nonprofit recovery organizations offering nonclinical substance use recovery support services in the state.

 

Opioid Overdose Reversal Drugs

Senate Bill 408/House Bill 411 mandate the MDH to deliver an annual report to designated General Assembly committees by December 1 from 2024 to 2026. This report must cover (1) the list of current opioid overdose reversal drugs approved by the FDA and (2) whether MDH has included each FDA-approved opioid overdose reversal drug in a standing order. If any such drug hasn’t been included, the report must outline the reasons for its exclusion. The bill sponsors were Senator Kathy Klausmeier (D – Baltimore County) and Delegate Nic Kipke (R – Anne Arundel County).

 

Naloxone with Defibrillators

MDH’s Overdose Response Program (ORP) facilitates the distribution of FDA-approved opioid overdose reversal drugs to specific individuals at no cost, through various providers, programs, and entities. Additionally, Maryland has a statewide standing order for these drugs, allowing any Maryland-licensed pharmacist to provide unlimited prescriptions and refills of naloxone and its administration devices to any individual.

In alignment with the state’s objective to enhance access to opioid overdose reversal drugs, Senate Bill 1099, sponsored by Senator Will Smith (D – Montgomery County), extends the scope of the Public Access Automated External Defibrillator Program. This expansion includes an initiative to equip each automated external defibrillator placed in a public building with up to two doses of naloxone.

 

Opioid-Related Emergency Medical Conditions

Senator Mike McKay (R – Garrett, Allegany, & Washington Counties) and Delegate Vaughn Stewart (D -Montgomery County) introduced and passed Senate Bill 1071/House Bill 1155 to mandate every hospital to develop and uphold protocols and capabilities for three key purposes:

(1) administering evidence-based interventions to mitigate the risk of further harm or fatality following discharge of a patient post opioid-related overdose or emergency visit;

(2) stocking specified medications for treating opioid use disorder (OUD); and

(3) providing medication for OUD to patients presenting with opioid-related emergencies in the hospital emergency department.

The bill has staggered effective dates of October 1, 2024 and January 1, 2025.

 

Natural Psychedelic Substances

Senate Bill 1009/House Bill 548 create the Task Force on Responsible Use of Natural Psychedelic Substances. This task force is tasked with examining the use of natural psychedelic substances, including naturally derived psilocybin, and proposing recommendations for potential alterations to state law, policy, and practices. The aim is to establish a Maryland Natural Psychedelic Substance Access Program and shift away from criminalizing behaviors related to natural psychedelic substances.

Senator Brian Feldman (D – Montgomery County) and Delegate Pam Guzzone (D – Howard County) were the primary sponsors of this legislation, which becomes effective July 1, 2024.

 

Student Telehealth Appointments

Senate Bill 492/House Bill 522, introduced by Senator Cheryl Kagan (D – Montgomery County) and Delegate Dana Jones (D – Anne Arundel County), provides detailed guidelines and regulations concerning telehealth services in Maryland schools. The bill defines “telehealth” as the use of telecommunications technologies by healthcare practitioners to provide services to patients at different physical locations. According to the bill, each middle and high school must designate a private space for student telehealth appointments. This space must be private, have internet access, include at least one seating option with a flat surface and nearby electrical outlet to accommodate a laptop, and importantly, it must not be a bathroom or closet. Moreover, the bill mandates that schools implement measures to ensure the safety and privacy of students participating in telehealth appointments. The bill does not mandate schools to construct new spaces to comply with these requirements nor does it change the responsibilities of healthcare providers regarding the disclosure of medical records under current law, especially in emergency situations. The bill becomes effective July 1, 2024.

 

Coaches Mental Health Training

Senate Bill 165/House Bill 204 mandates mental health training for coaches in all public schools and institutions of higher education in Maryland that offer athletic programs. MSDE and MHEC will collaborate with the MDH, local boards of education, and the Maryland Public Secondary Schools Athletic Association to develop guidelines for recognizing mental illness and behavioral distress indicators, including depression, trauma, violence, youth suicide, and substance abuse. For elementary and secondary schools, an “athletic program” refers to intramural, interscholastic, or other school-sponsored athletic programs meeting State Board of Education criteria. For higher education institutions, it includes any intercollegiate athletic program. The bill, sponsored by Senator Shelly Hettleman (D – Baltimore County) and Delegate Dalya Attar (D – Baltimore City), becomes effective on July 1, 2024.

 

Physician Assistants

Senate Bill 167/House Bill 806, introduced by Senator Mary Beth Carozza (R – Somerset, Worcester, & Wicomico Counties) and Delegate Ken Kerr (D – Frederick County), proposes significant changes to the licensure, practice, and regulation of Physician Assistants (PAs) in Maryland.

The bill changes the education requirements for obtaining a PA license. Applicants must now have completed an educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant or, if completed before 2001, accredited by the Committee on Allied Health Education and Accreditation or the Commission on Accreditation of Allied Health Education Programs. Additionally, applicants must pass the Physician Assistant National Certifying Examination administered by the National Commission on Certification of Physician Assistants.

The bill replaces delegation agreements with collaboration agreements between PAs and individual physicians or groups of physicians. These agreements outline the collaboration between the PA and the physician(s) and must be approved by the Maryland Board of Physicians (MBP). Collaboration agreements define the communication and decision-making process among healthcare providers related to patient treatment and care. PAs may practice only after providing notice to MBP of the executed collaboration agreement and maintaining a copy at the practice setting. MBP can audit and review collaboration agreements, and a patient care team physician may not delegate medical acts to more than eight PAs at one time. Collaboration agreements can be modified or terminated by MBP or the PA under certain conditions.

PAs are defined as individuals licensed by MBP to practice under the collaboration agreement. They may not practice independently but can delegate duties to unlicensed individuals under certain conditions. Patient services provided by PAs include obtaining health histories, physical examinations, diagnosing and managing medical treatment, interpreting patient data, prescribing medication, providing consultations, and more. PAs may not perform medical acts beyond their 41 license, education, training, or that are not customary to the practice of the patient care team physicians listed in the collaboration agreement. PAs can only perform advanced duties after obtaining MBP approval through collaboration agreements. Documentation of authority for advanced duties must be maintained at the facility.

MBP can modify the performance of advanced duties based on recommendations from the Physician Assistant Advisory Committee. Finally, PAs can prescribe, dispense, and administer controlled dangerous substances under collaboration agreements with specific attestations and conditions. MBP can take disciplinary actions against PAs or patient care team physicians who practice inconsistently with requirements. Penalties may include reprimand, probation, suspension, or revocation of license. Furthermore, PAs are included in the definition of “healthcare provider” for health care malpractice claims.

The bill becomes effective on October 1, 2024.