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§ 14-205. Benefits for health care services; payments and rates for providers

West's Annotated Code of MarylandInsuranceEffective: July 1, 2011

West's Annotated Code of Maryland
Insurance (Refs & Annos)
Title 14. Entities that Act as Health Insurers
Subtitle 2. Preferred Provider Organizations (Refs & Annos)
Effective: July 1, 2011
MD Code, Insurance, § 14-205
§ 14-205. Benefits for health care services; payments and rates for providers
Currentness
Direct payments to health care provider or through reimbursement to insured
(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.
Services rendered by nonpreferred providers
(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.
Rates approved by Commission not unfair discrimination
(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.

Credits

Added by Acts 1997, c. 35, § 2, eff. Oct. 1, 1997. Amended by Acts 2010, c. 537, § 1, eff. July 1, 2011.
Formerly Art. 48A, §§ 655, 657.
MD Code, Insurance, § 14-205, MD INSURANCE § 14-205
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
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