1. A. A payor may request that the Commission issue or renew a waiver from the requirement to meet a benchmark in Regulation .03 of this chapter by the demonstration of the following extenuating circumstances:

   1. (1) For an insurer or nonprofit health service plan, a premium volume that is less than $1,000,000 annually in the State;
   2. (2) For a group model health maintenance organization, as defined in Health-General Article, §19-713.6, Annotated Code of Maryland, preauthorizations of health care services requested by providers not employed by the group model health maintenance organization; or
   3. (3) Other circumstances determined by the Executive Director to be extenuating.

2. B. Submission of Request for Waiver or Renewal of Waiver.

   1. (1) A request for a waiver or renewal of waiver shall be in writing and shall include:

      1. (a) An identification of each preauthorization benchmark for which a waiver is requested; and
      2. (b) A detailed explanation of the extenuating circumstances necessitating the waiver.

   2. (2) A request for a waiver shall be filed with the Commission in accordance with the following:

      1. (a) For renewal of a waiver, no later than 30 days prior to its expiration; or
      2. (b) For a payor that becomes authorized to provide benefits or services within the State of Maryland after October 1, 2012, within 3 months after the date the payor is authorized to provide benefits or services within the State.

3. C. Issuance of Waiver.

   1. (1) The Executive Director may issue a waiver from a preauthorization benchmark to a payor that demonstrates extenuating circumstances within this chapter.
   2. (2) The Executive Director will review and provide a decision to approve or deny all waiver requests within a reasonable time frame.
   3. (3) A waiver or renewal of a waiver shall be valid for 2 years, unless withdrawn by the Executive Director.

4. D. Withdrawal of Waiver.

   1. (1) The Executive Director may withdraw a waiver or renewal of a waiver if the Executive Director determines that the payor can no longer demonstrate extenuating circumstances.
   2. (2) If the Executive Director withdraws a waiver or renewal of waiver, the Executive Director shall notify the payor, setting forth in writing the reasons for withdrawal.
   3. (3) After a waiver or a renewal of a waiver is withdrawn, a payor shall submit a plan to the Executive Director within 30 days that includes a timeline for attaining each benchmark in Regulation .03 of this chapter in a format approved by the Commission.

5. E. Review of Denial or Withdrawal of Waiver.

   1. (1) If the Executive Director has denied or withdrawn a waiver, a payor may seek Commission review of the denial or withdrawal by filing a written request for review with the Commission within 20 days of receipt of the Executive Director’s notice of denial or withdrawal of a waiver, which shall:

      1. (a) State with particularity the grounds and factual basis for a payor’s disagreement with the denial or withdrawal decision;
      2. (b) Specify the remedy requested; and
      3. (c) If desired, include a written request to orally address the Commission, which shall be scheduled if requested.
   2. (2) The full Commission may review the written request for review of a denial or withdrawal of a waiver directly or, at the discretion of the Chair of the Commission, appoint a Commissioner to review the request submitted under §E(1) of this regulation, who will make a recommendation to the full Commission.
   3. (3) If a written request was submitted under §E(1)(c) of this regulation, a payor may orally address the Commission before a determination is made by the Commission as to whether or not to issue or withdraw a waiver.
   4. (4) After reviewing and considering a payor’s written request for review of the denial or withdrawal decision and any oral argument, if applicable, the full Commission shall issue a written decision affirming, reversing, or modifying the decision reviewed.
6. F. A waiver or renewal of waiver from the requirements of this chapter may not be sold, assigned, leased, or transferred.

Authority: Health-General Article, §§19-101 and 19-108.2, Annotated Code of Maryland

Effective date: February 18, 2013 (40:3 Md. R. 218)

Regulation .01 amended effective January 9, 2023 (49:27 Md. R. 1110)

Regulation .02B amended effective October 12, 2015 (42:20 Md. R. 1265); January 9, 2023 (49:27 Md. R. 1110)

Regulation .03 amended effective October 12, 2015 (42:20 Md. R. 1265); January 9, 2023 (49:27 Md. R. 1110)

Regulation .04 amended effective October 12, 2015 (42:20 Md. R. 1265); January 9, 2023 (49:27 Md. R. 1110)

Regulation .05 amended effective October 12, 2015 (42:20 Md. R. 1265); January 9, 2023 (49:27 Md. R. 1110)