Challenges, Successes, Priorities and Issues

Therese M. Goldsmith, Maryland Insurance Commissioner, Speaks Out20131205-4727

In spite of the challenges of the new healthcare exchange in Maryland, Insurance Commissioner Goldsmith finds much to celebrate.

Maryland Physician Magazine: What are the greatest challenges you have faced over the past three years in regulating healthcare insurance in the state?

Insurance Commissioner Goldsmith: Implementation of the Affordable Care Act (ACA) has been a major focus of healthcare insurance regulation over the past three years. The Maryland Insurance Administration (MIA) has drafted several bills, passed by the General Assembly and signed by Governor O’Malley, that align Maryland law with ACA requirements. We have issued dozens of bulletins and other guidance to insurance carriers on ACA-related matters ranging from rate and policy form-filing requirements, to early policy renewal options, to provider networks for substance use disorder services, to healthcare insurance coverage for transgender individuals. Our Consumer Education and Advocacy Unit staff has participated in hundreds of community events across the state to help make consumers more aware of ACA reforms and their options in Maryland’s individual and small group healthcare insurance markets.

Maryland Physician: What have been some of the successes to date?

ICG: In 2011, the Center for Consumer Information and Insurance Oversight (CCIIO), a part of the Centers for Medicare and Medicaid Services (CMS) within the U.S. Department of Health and Human Services (HHS), determined that the MIA’s review and approval process for healthcare insurance premium rates satisfied criteria established in new federal regulations, which meant that CCIIO would defer to the MIA’s decisions regarding the reasonableness of healthcare insurance premium rate increases in Maryland’s individual and small group healthcare insurance markets.  The MIA was awarded nearly $5 million in federal grant funds to enhance its rate review process. For 2014, Maryland’s healthcare insurance premium rates are among the most competitive in the country.

Maryland Physician: What have been the major impacts of the ACA on your agency’s work? 

ICG: New requirements and open enrollment periods under federal and state law have required MIA staff to review and issue determinations on unprecedented volumes of premium rate and policy form filings within a compressed time period. The MIA also has reviewed and approved training programs for new consumer assistance workers in the healthcare insurance marketplace, including navigators, certified application counselors, and consolidated service center employees assisting consumers with plans sold through Maryland’s new healthcare insurance marketplace, Maryland Healthcare Connection. I’m proud of our knowledgeable and dedicated staff that met these challenges.

Maryland Physician: How will healthcare in Maryland be different going forward as a result of the ACA?

ICG: In Maryland, we see the value of the ACA every day. Individuals and families now can purchase a healthcare benefit plan without the risk of being turned down or paying higher premiums because of a pre-existing condition. Non-grandfathered healthcare benefit plans issued or renewed in the individual and small-group markets must include a core set of benefits – known as essential healthcare benefits – and may not impose annual or lifetime limits on those benefits.

The ACA has saved seniors millions of dollars in prescription drug costs, made tax credits for insurance available to eligible small businesses, and allowed young adults to remain on their parents’ coverage until age 26. Advance premium tax credits and cost-sharing subsidies have put private healthcare insurance within the financial reach of many Marylanders who previously could not afford it.

Maryland Physician: What are your healthcare insurance priorities for 2014?

ICG: The MIA has incorporated a 30-day public comment period in our rate review process, and we post all healthcare insurance rate decisions on our website. In 2014, we are working to enhance the process for public comment and to make our premium-rate decision documents more consumer-friendly. We also are focusing on our responsibility to enforce all new ACA-related laws and regulations applicable to insurance carriers, producers, navigators and other consumer assistance workers for whom we have regulatory oversight authority.

Maryland Physician: Describe key issues involving payment denials related to medical necessity, and what steps you take to help consumers or physicians who have received those denials.

ICG: Each complaint that the MIA receives from consumers or providers relating to the medical necessity of a service is unique because it is based on whether the service is medically necessary, appropriate and efficient for that particular covered person.

Unless the complaint is an emergency case and the service has not yet been provided, the complainant must first file an “internal appeal” to the insurance carrier. If the carrier upholds its denial, a complaint may be filed “externally” with the MIA. At that point, the MIA staff gathers all the medical records that are provided by the complainant, the carrier and the healthcare provider regarding the condition and the denial, including the determinations by the carrier, and sends them to an independent review organization (IRO) for an independent, unbiased review. The cost of the review is paid by the carrier.

A physician who is board-certified in the specialty of the case that is being considered must review the case. The IRO is asked to opine on whether the particular service is medically necessary, appropriate and efficient for the particular covered person. It also is asked to determine whether the medical criteria that the carrier used were objective, clinically valid, compatible with established principles of healthcare and flexible enough to allow deviations from norms when justified on a case-by-case basis.

If the IRO determines that the care was medically necessary for the individual, the carrier is required to pay the benefits under the contract. Generally, the carrier will pay for the benefits without requiring an Order of the Commissioner. If the medical criteria are not acceptable, the carrier is ordered to file new criteria and use them going forward.

A detailed analysis of the medical necessity complaints investigated by the MIA is provided in the annual Appeals and Grievance report that is available on the MIA’s website at Generally, it is well worth the effort to appeal a medical necessity denial. The 2012 Appeals and Grievance Report shows that carriers, on appeal, overturn their initial denials 52.3% of the time and modify denials another 4.3% of the time. For medical necessity complaints that are filed with the MIA, 63.1% of the denials were overturned during the MIA’s investigation process in 2012.

Maryland Physician: How can the MIA and Maryland physicians work together to benefit patients?

ICG: Physicians and other healthcare providers can file complaints with the MIA on their patients’ behalf regarding carrier coverage decisions, and can file complaints on their own behalf regarding carrier business practices that do not comply with state law. Physicians should be prepared to provide specific facts – broad allegations of carrier misconduct, without more, generally do not provide an adequate basis on which to conduct a meaningful investigation. It also is helpful to hear physicians’ perspectives on areas in which insurance carriers or others may need additional regulatory guidance.

Maryland Physician: Describe how the MIA helps physicians select medical malpractice insurance.

ICG: Each year, the MIA produces a medical malpractice insurance rate comparison guide to help medical professionals find the plans best suited to their needs. The guide includes tips on how to shop for coverage and suggestions for other types of coverage medical professionals might want to consider.

Maryland Physician: You have been both a certified speech-language pathologist and former litigator focused on healthcare fraud and abuse – a very unique professional background. What mentors have helped develop the skills you use as commissioner?

ICG: I am privileged to have worked with at least two people I would consider mentors: one a speech-language pathologist, the other an attorney. From the attorney I learned to assume nothing. Through his example, he taught me to be a more critical and analytical thinker and to examine an issue from multiple perspectives. From the speech-language pathologist I learned the importance of service. One of his favorite quotes, from Albert Schweitzer, is this: “I don’t know what your destiny will be, but one thing I know: the only ones among you who will be really happy are those who will have sought and found how to serve.”

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