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§ 15-2102. Capitated payments not considered acts of insurance business

West's Annotated Code of MarylandInsuranceEffective: October 1, 2022

West's Annotated Code of Maryland
Insurance (Refs & Annos)
Title 15. Health Insurance
Subtitle 21. Capitated Payments (Refs & Annos)
Effective: October 1, 2022
MD Code, Insurance, § 15-2102
§ 15-2102. Capitated payments not considered acts of insurance business
Currentness
Capitated payments
(a) This section applies to arrangements under a health benefit plan offered by a carrier or a self-funded group health insurance plan in which a capitated payment is:
(1) calculated as a fixed amount per member or participant assigned or attributed to the health care practitioner or set of health care practitioners;
(2) to cover the provision of a set of services defined in the health care practitioner's or set of health care practitioners' contract and rendered by the health care practitioner or set of health care practitioners; and
(3) paid periodically regardless of utilization of the services by the members or participants.
Capitated payments not considered acts of insurance business
(b) Subject to the requirements of subsection (c) of this section, a health care practitioner or set of health care practitioners is not engaged in insurance business as described in § 4-205 of this article solely because the health care practitioner or set of health care practitioners enters into a contract with a carrier that includes capitated payments for services provided by the health care practitioner or set of health care practitioners.
Conditions to not be considered acts of insurance business
(c) A health care practitioner or set of health care practitioners is not engaged in insurance business as described in § 4-205(c) of this article solely because the health care practitioner or set of health care practitioners enters into a contract with an administrator that includes capitated payments for services provided by the health care practitioner or set of health care practitioners to members of a self-funded group health plan if:
(1) the health care practitioner or set of health care practitioners participates in the administrator's network and accepts capitated payments;
(2) the self-funded group health plan retains the obligation to provide access to covered health care benefits to participants; and
(3) the contract does not include other reimbursement arrangements that are considered acts of an insurance business under § 4-205(c) of this article.
Construction of section
(d) Notwithstanding subsections (b) and (c) of this section, nothing in this section may be construed to:
(1) alter any requirement for a carrier or self-funded group health plan to pay a hospital or related institution the rate approved by the Health Services Cost Review Commission for hospital services; or
(2) supersede the Health Services Cost Review Commission's jurisdiction or authority over rate review and approval for hospital services.

Credits

Added by Acts 2022, c. 297, § 1, eff. Oct. 1, 2022; Acts 2022, c. 298, § 1, eff. Oct. 1, 2022.
MD Code, Insurance, § 15-2102, MD INSURANCE § 15-2102
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.
End of Document