2013 Maryland Code
INSURANCE
§ 14-205 - Benefits for health care services; payments to and rates for providers. [Amendment subject to abrogation]


MD Ins Code § 14-205 (2013) What's This?

§14-205. IN EFFECT

(a) If a preferred provider insurance policy offered by an insurer provides benefits for a service that is within the lawful scope of practice of a health care provider licensed under the Health Occupations Article, an insured covered by the preferred provider insurance policy is entitled to receive the benefits for that service either through direct payments to the health care provider or through reimbursement to the insured.

(b) (1) A preferred provider insurance policy offered by an insurer under this subtitle shall provide for payment of services rendered by nonpreferred providers as provided in this subsection.

(2) Unless the insurer demonstrates to the satisfaction of the Commissioner that an alternative level of payment is more appropriate, for each covered service under a preferred provider insurance policy, the difference between the coinsurance percentage applicable to nonpreferred providers and the coinsurance percentage applicable to preferred providers may not be greater than 20 percentage points.

(3) If the preferred provider insurance policy contains a provision for the insured to pay the balance bill, the provision may not apply to an on-call physician or a hospital-based physician who has accepted an assignment of benefits in accordance with § 14-205.2 of this subtitle.

(4) The insurer’s allowed amount for a health care service covered under the preferred provider insurance policy provided by nonpreferred providers may not be less than the allowed amount paid to a similarly licensed provider who is a preferred provider for the same health care service in the same geographic region.

(c) (1) In this subsection, “unfair discrimination” means an act, method of competition, or practice engaged in by an insurer:

(i) that is prohibited by Title 27, Subtitle 2 of this article; or

(ii) that, although not specified in Title 27, Subtitle 2 of this article, the Commissioner believes is unfair or deceptive and that results in the institution of an action by the Commissioner under § 27-104 of this article.

(2) If the rates for each institutional provider under a preferred provider insurance policy offered by an insurer vary based on individual negotiations, geographic differences, or market conditions and are approved by the Health Services Cost Review Commission, the rates do not constitute unfair discrimination under this article.

14-205. // EFFECTIVE SEPTEMBER 30, 2015 PER CHAPTER 537 OF 2010 //

(a) If a preferred provider insurance policy offered by an insurer provides benefits for a service that is within the lawful scope of practice of a health care provider licensed under the Health Occupations Article, an insured covered by the preferred provider insurance policy is entitled to receive the benefits for that service either through direct payments to the health care provider or through reimbursement to the insured.

(b) (1) A preferred provider insurance policy offered by an insurer under this subtitle shall provide for payment of services rendered by nonpreferred providers as provided in this subsection.

(2) Unless the insurer demonstrates to the satisfaction of the Commissioner that an alternative level of payment is more appropriate, aggregate payments made in a full calendar year to nonpreferred providers, after all deductible and copayment provisions have been applied, on average may not be less than 80% of the aggregate payments made in that full calendar year to preferred providers for similar services, in the same geographic area, under their provider service contracts.

(c) (1) In this subsection, “unfair discrimination” means an act, method of competition, or practice engaged in by an insurer:

(i) that is prohibited by Title 27, Subtitle 2 of this article; or

(ii) that, although not specified in Title 27, Subtitle 2 of this article, the Commissioner believes is unfair or deceptive and that results in the institution of an action by the Commissioner under § 27-104 of this article.

(2) If the rates for each institutional provider under a preferred provider insurance policy offered by an insurer vary based on individual negotiations, geographic differences, or market conditions and are approved by the Health Services Cost Review Commission, the rates do not constitute unfair discrimination under this article.

§ 14-205 - Benefits for health care services; payments to and rates for providers (Abrogation of amendment effective September 30, 2015.)

(a) Benefits for health care services. -- If a preferred provider insurance policy offered by an insurer provides benefits for a service that is within the lawful scope of practice of a health care provider licensed under the Health Occupations Article, an insured covered by the preferred provider insurance policy is entitled to receive the benefits for that service either through direct payments to the health care provider or through reimbursement to the insured.

(b) Payments to nonpreferred providers. --

(1) A preferred provider insurance policy offered by an insurer under this subtitle shall provide for payment of services rendered by nonpreferred providers as provided in this subsection.

(2) Unless the insurer demonstrates to the satisfaction of the Commissioner that an alternative level of payment is more appropriate, aggregate payments made in a full calendar year to nonpreferred providers, after all deductible and copayment provisions have been applied, on average may not be less than 80% of the aggregate payments made in that full calendar year to preferred providers for similar services, in the same geographic area, under their provider service contracts.

(c) Approved rates for institutional providers. --

(1) In this subsection, "unfair discrimination" means an act, method of competition, or practice engaged in by an insurer:

(i) that is prohibited by Title 27, Subtitle 2 of this article; or

(ii) that, although not specified in Title 27, Subtitle 2 of this article, the Commissioner believes is unfair or deceptive and that results in the institution of an action by the Commissioner under § 27-104 of this article.

(2) If the rates for each institutional provider under a preferred provider insurance policy offered by an insurer vary based on individual negotiations, geographic differences, or market conditions and are approved by the Health Services Cost Review Commission, the rates do not constitute unfair discrimination under this article.

§ 14-205 - 1. Option to include preferred or nonpreferred providers.

(a) In general. -- The Commissioner may authorize an insurer or nonprofit health service plan to offer a preferred provider insurance policy that conditions the payment of benefits on the use of preferred providers if the insurer or nonprofit health service plan:

(1) has demonstrated to the Secretary of Health and Mental Hygiene that the provider panel of the insurer or nonprofit health service plan complies with the regulations adopted under § 19-705.1(b)(1)(i)2 of the Health - General Article; and

(2) does not restrict payment for covered services provided by nonpreferred providers:

(i) for emergency services, as defined in § 19-701 of the Health - General Article;

(ii) for an unforeseen illness, injury, or condition requiring immediate care; or

(iii) as required under § 15-830 of this article.

(b) Option to be offered. --

(1) If an employer, association, or other private group arrangement offers health benefit plan coverage to employees or individuals only through preferred providers, then the insurer or nonprofit health service plan with which the employer, association, or other private group arrangement is contracting for the coverage shall offer an option to include preferred and nonpreferred providers as an additional benefit for an employee or individual, at the employee's or individual's option, to accept or reject.

(2) The insurer or nonprofit health service plan shall provide to each employer, association, or other private group arrangement a disclosure statement on the group application that an option to include preferred and nonpreferred providers is available for the individual or employee to accept or reject.

(c) Increase of premium authorized for exercise of option. -- An employer, association, or other private group arrangement may require an employee or individual that accepts the additional coverage for preferred and nonpreferred providers to pay a premium greater than the amount of the premium for the coverage offered for preferred providers only.

§ 14-205 - 2. Collection of money for services rendered by on-call physician or hospital based physician. [Section subject to abrogation]

(a) Applicability of section. -- Except as otherwise provided, this section applies to both on-call physicians and hospital-based physicians who:

(1) are nonpreferred providers;

(2) obtain an assignment of benefits from an insured; and

(3) notify the insurer of an insured in a manner specified by the Commissioner that the on-call physician or hospital-based physician has obtained and accepted the assignment of benefits from the insured.

(b) Limitation of liability of insured. --

(1) Except as provided in paragraph (3) of this subsection, an insured may not be liable to an on-call physician or a hospital-based physician subject to this section for covered services rendered by the on-call physician or hospital-based physician.

(2) An on-call physician or hospital-based physician subject to this section or a representative of an on-call physician or hospital-based physician subject to this section may not:

(i) collect or attempt to collect from an insured of an insurer any money owed to the on-call physician or hospital-based physician by the insurer for covered services rendered to the insured by the on-call physician or hospital-based physician; or

(ii) maintain any action against an insured of an insurer to collect or attempt to collect any money owed to the on-call physician or hospital-based physician by the insurer for covered services rendered to the insured by the on-call physician or hospital-based physician.

(3) An on-call physician or hospital-based physician subject to this section or a representative of an on-call physician or hospital-based physician subject to this section may collect or attempt to collect from an insured of an insurer:

(i) any deductible, copayment, or coinsurance amount owed by the insured for covered services rendered to the insured by the on-call physician or hospital-based physician;

(ii) if Medicare is the primary insurer and the insurer is the secondary insurer, any amount up to the Medicare approved or limiting amount, as specified under the federal Social Security Act, that is not owed to the on-call physician or hospital-based physician by Medicare or the insurer after coordination of benefits has been completed, for Medicare covered services rendered to the insured by the on-call physician or hospital-based physician; and

(iii) any payment or charges for services that are not covered services.

(c) Payment for services rendered by on-call physicians. --

(1) This subsection applies only to on-call physicians subject to this section.

(2) For a covered service rendered to an insured of an insurer by an on-call physician subject to this section, the insurer or its agent:

(i) shall pay the on-call physician within 30 days after the receipt of a claim in accordance with the applicable provisions of this title; and

(ii) shall pay a claim submitted by the on-call physician for a covered service rendered to an insured in a hospital, no less than the greater of:

1. 140% of the average rate the insurer paid for the 12-month period that ends on January 1 of the previous calendar year in the same geographic area, as defined by the Centers for Medicare and Medicaid Services, for the same covered service, to similarly licensed providers under written contract with the insurer; or

2. the average rate the insurer paid for the 12-month period that ended on January 1, 2010, in the same geographic area, as defined by the Centers for Medicare and Medicaid Services, for the same covered service to a similarly licensed provider not under written contract with the insurer, inflated by the change in the Medicare Economic Index from 2010 to the current year.

(d) Payment for services rendered by hospital-based physicians. --

(1) This subsection applies only to hospital-based physicians subject to this section.

(2) For a covered service rendered to an insured of an insurer by a hospital-based physician subject to this section, the insurer or its agent:

(i) shall pay the hospital-based physician within 30 days after the receipt of the claim in accordance with the applicable provisions of this title; and

(ii) shall pay a claim submitted by the hospital-based physician for a covered service rendered to an insured no less than the greater of:

1. 140% of the average rate the insurer paid for the 12-month period that ends on January 1 of the previous calendar year in the same geographic area, as defined by the Centers for Medicare and Medicaid Services, for the same covered service, to similarly licensed providers, who are hospital-based physicians, under written contract with the insurer; or

2. the final allowed amount of the insurer for the same covered service for the 12-month period that ended on January 1, 2010, inflated by the change in the Medicare Economic Index to the current year, to the hospital-based physician billing under the same federal tax identification number the hospital-based physician used in calendar year 2009.

(e) Calculation of average rate paid to similarly licensed providers. --

(1) For the purposes of subsections (c)(2)(ii)1 and (d)(2)(ii)1 of this section, an insurer shall calculate the average rate paid to similarly licensed providers under written contract with the insurer for the same covered service by summing the contracted rate for all occurrences of the Current Procedural Terminology Code for that covered service and then dividing by the total number of occurrences of the Current Procedural Terminology Code.

(2) For the purposes of subsection (c)(2)(ii)2 of this section, an insurer shall calculate the average rate paid to similarly licensed providers not under written contract with the insurer for the same covered service by summing the rates paid to similarly licensed providers not under written contract with the insurer for all occurrences of the Current Procedural Terminology Code for that covered service and then dividing by the total number of occurrences of the Current Procedural Terminology Code.

(f) Disclosure of reimbursement rate. -- An insurer shall disclose, on request of an on-call physician or hospital-based physician subject to this section, the reimbursement rate required under subsection (c)(2)(ii) or (d)(2)(ii) of this section.

(g) Reimbursement. --

(1) An insurer may seek reimbursement from an insured for any payment under subsection (c)(2)(ii) or (d)(2)(ii) of this section for a claim or portion of a claim submitted by an on-call physician or hospital-based physician subject to this section and paid by the insurer that the insurer determines is the responsibility of the insured based on the insurance contract.

(2) The insurer may request and the on-call physician or hospital-based physician shall provide adjunct claims documentation to assist in making the determination under paragraph (1) of this subsection or under subsection (c) of this section.

(h) Complaint or civil action. --

(1) An on-call physician or hospital-based physician subject to this section may enforce the provisions of this section by filing a complaint against an insurer with the Administration or by filing a civil action in a court of competent jurisdiction under § 1-501 or § 4-201 of the Courts Article.

(2) The Administration or a court shall award reasonable attorney's fees if the Administration or court finds that:

(i) the insurer's conduct in maintaining or defending the proceeding was in bad faith; or

(ii) the insurer acted willfully in the absence of a bona fide dispute.

(i) Investigation and enforcement. -- The Administration may take any action authorized under this article, including conducting an examination under Title 2, Subtitle 2 of this article, to investigate and enforce a violation of the provisions of this section.

(j) Penalty. -- In addition to any other penalties under this article, the Commissioner may impose a penalty not to exceed $ 5,000 on an insurer for each violation of this section.

(k) Regulations. -- The Administration, in consultation with the Maryland Health Care Commission, shall adopt regulations to implement this section.

§ 14-205 - 2. Collection of money for services rendered by on-call physician or hospital based physician (Abrogation of section effective September 30, 2015.)

Abrogated.

§ 14-205 - 3. Assignment of benefits. [Section subject to abrogation]

(a) Applicability. -- This section does not apply to on-call physicians or hospital-based physicians.

(b) Limitations on insurer regarding assignment and reimbursement. -- An insurer may not:

(1) prohibit the assignment of benefits to a provider who is a physician by an insured; or

(2) refuse to directly reimburse a nonpreferred provider who is a physician under an assignment of benefits.

(c) Information with payment. -- If an insured has not provided an assignment of benefits, the insurer shall include the following information with the payment to the insured for health care services rendered by the nonpreferred provider who is a physician:

(1) the specific claim covered by the payment;

(2) the amount paid for the claim;

(3) the amount that is the insured's responsibility; and

(4) a statement instructing the insured to use the payment to pay the nonpreferred provider in the event the insured has not paid the nonpreferred provider in full for the health care services rendered by the nonpreferred provider.

(d) Information required prior to performing a health care service. -- If a physician who is a nonpreferred provider seeks an assignment of benefits from an insured, the physician shall provide the following information to the insured, prior to performing a health care service:

(1) a statement informing the insured that the physician is a nonpreferred provider;

(2) a statement informing the insured that the physician may charge the insured for noncovered services;

(3) a statement informing the insured that the physician may charge the insured the balance bill for covered services;

(4) an estimate of the cost of services that the physician will provide to the insured;

(5) any terms of payment that may apply; and

(6) whether interest will apply and, if so, the amount of interest charged by the physician.

(e) Submission of disclosure form. -- A physician who is a nonpreferred provider shall submit the disclosure form developed by the Commissioner under subsection (f) of this section to document to the insurer the assignment of benefits by an insured.

(f) Development of disclosure forms. -- The Commissioner shall develop disclosure forms to implement the requirements under subsections (c) and (d) of this section.

(g) Refusal to directly reimburse. -- Notwithstanding the provisions of subsection (b) of this section, an insurer may refuse to directly reimburse a nonpreferred provider under an assignment of benefits if:

(1) the insurer receives notice of the assignment of benefits after the time the insurer has paid the benefits to the insured;

(2) the insurer, due to an inadvertent administrative error, has previously paid the insured;

(3) the insured withdraws the assignment of benefits before the insurer has paid the benefits to the nonpreferred provider; or

(4) the insured paid the nonpreferred provider the full amount due at the time of service.

§ 14-205 - 3. Assignment of benefits (Abrogation of section effective September 30, 2015.)

Abrogated.

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