Section 14-205 - Benefits for health care services; payments to and rates for providers. - Maryland Statutes

§ 14-205. Benefits for health care services; payments to and rates for providers. [Subject to amendment effective July 1, 2011; amended version follows this section].
 

(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. 
 

[An. Code 1957, art. 48A, §§ 655, 657; 1997, ch. 35, § 2.]