Managed Care E&O & ACO Liability Insurance in Maryland

Maryland at a glance

Primary regulator

Maryland Insurance Administration

Oversees managed care licensing, network adequacy, and utilization-review compliance in Maryland.

Distinctive payment structure

All-payer hospital rate-setting under the Health Services Cost Review Commission

Maryland is the only state operating this federally approved global-budget model for hospital payment.

Medicaid managed care program

HealthChoice

Delivers Medicaid benefits through contracted MCOs that often delegate credentialing and utilization review.

External review pathway

Health-General Article independent review process

Provides binding external review of adverse utilization-review decisions after internal appeals.

Maryland's all-payer rate-setting adds a distinct wrinkle

Maryland is the only state operating under a federally approved all-payer hospital rate-setting system, administered by the Health Services Cost Review Commission, which sets uniform hospital rates across payers rather than leaving them to negotiation. This structure changes how utilization-review and network-adequacy disputes play out, since payment amounts are largely fixed and disputes concentrate instead on medical necessity, admission criteria, and care coordination under the state's global budget revenue model for hospitals.

HealthChoice and MCO delegation

Maryland's Medicaid program, HealthChoice, delivers benefits through contracted managed care organizations that frequently delegate credentialing and utilization review to network providers. An error at that delegated level — an incomplete credentialing file, a missed appeal deadline — can generate a claim against the delegating MCO, so E&O coverage discussions should confirm delegated functions are included rather than assumed.

External review under the Health-General Article

Maryland law provides members a right to independent external review of adverse utilization-review decisions under the Health-General Article, once internal grievance steps are exhausted, with the Maryland Insurance Administration certifying the independent review organizations that decide these cases. The documentation an organization keeps at the internal-grievance stage is the record most likely to matter if a dispute later becomes an E&O claim.

Coordinating E&O with cyber and fiduciary coverage

A managed-care E&O policy responds to allegations tied to utilization review, credentialing, and claims administration, while member data breaches sit with a cyber policy and ERISA fiduciary duties sit with a separate fiduciary liability form. Maryland MCOs and hospital-affiliated networks operating under the state's global budget model should review all three lines together given how tightly care coordination and data-sharing are woven into that payment structure.

Who we write this for in Maryland

Managed care E&O FAQs for Maryland