Definitions applicable to Section 14-205.2; Determining amounts payable to certain out-of-network physicians
Section 14-201. Definitions applicable to Section 14-205.2
(a) In this subtitle the following words have the meanings indicated.
(b) “Allowed amount” means the dollar amount that an insurer determines is the value of the health care service provided by a provider before any cost sharing amounts are applied.
(c) “Assignment of benefits” means the transfer of health care coverage reimbursement benefits or other rights under a preferred provider insurance policy by an insured.
(d) “Balance bill” means the difference between a nonpreferred provider’s bill for a health care service and the insurer’s allowed amount.
(e) “Cost sharing amounts” means the amounts that an insured is responsible for under a preferred provider insurance policy, including any deductibles, coinsurance, or copayments.
(f) “Covered service” means a health care service that is a covered benefit under a preferred provider insurance policy.
(g) “Health care services” has the meaning stated in § 19-701 of the Health – General Article.
(h) “Hospital-based physician” means:
(1) a physician licensed in the State who is under contract to provide health care services to patients at a hospital; or
(2) a group physician practice that includes physicians licensed in the State that is under contract to provide health care services to patients at a hospital.
(i) “Insured” means a person covered for benefits under a preferred provider insurance policy offered or administered by an insurer.
(j) “Medicare economic index” means the fixed-weight input price index that:
(1) measures the weighted average annual price change for various inputs needed to produce physician services; and
(2) is used by the Centers for Medicare and Medicaid Services in the calculation of reimbursement of physician services under Title XVIII of the federal Social Security Act.
(k) “Nonpreferred provider” means a provider that is eligible for payment under a preferred provider insurance policy, but that is not a preferred provider under the applicable provider service contract.
(l) “On-call physician” means a physician who:
(1) has privileges at a hospital;
(2) is required to respond within an agreed upon time period to provide health care services for unassigned patients at the request of a hospital or a hospital emergency department; and
(3) is not a hospital-based physician.
(m) “Preferential basis” means an arrangement under which the insured or subscriber under a preferred provider insurance policy is entitled to receive health care services from preferred providers at no cost, at a reduced fee, or under more favorable terms than if the insured or subscriber received similar services from a nonpreferred provider.
(n) “Preferred provider” means a provider that has entered into a provider service contract.
(o) “Preferred provider insurance policy” means:
(1) a policy or insurance contract that is issued or delivered in the State by an insurer, under which health care services are to be provided to the insured by a preferred provider on a preferential basis; or
(2) another contract that is offered by an employer, third party administrator, or other entity, under which health care services are to be provided to the subscriber by a preferred provider on a preferential basis.
(p) “Provider” means a physician, hospital, or other person that is licensed or otherwise authorized to provide health care services.
(q) “Provider service contract” means a contract between a provider and an insurer, employer, third party administrator, or other entity, under which the provider agrees to provide health care services on a preferential basis under specific preferred provider insurance policies.
(r) “Similarly licensed provider” means:
(1) for a physician:
(i) a physician who is board certified or eligible in the same practice specialty; or
(ii) a group physician practice that contains board certified or eligible physicians in the same practice specialty; or
(2) for a health care provider who is not a physician, a health care provider who holds the same type of license or certification.
(s) “Subscriber” means a person covered for benefits under a preferred provider insurance policy issued by a person that is not an insurer.
See https://mgaleg.maryland.gov/mgawebsite/laws/StatuteText?article=gin§ion=14-201&enactments=false
Section 14-205.2. Determining amounts payable to certain out-of-network physicians
(a) 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)(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)(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)(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)(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) 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)(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)(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) 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) 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) The Administration, in consultation with the Maryland Health Care Commission, shall adopt regulations to implement this section.