MD
Maryland House Bill HB1148

Maryland 2022 Regular Session

Maryland House Bill HB1148 Compare Versions

OldNewDifferences
1- LAWRENCE J. HOGAN, JR., Governor Ch. 297
21
3-– 1 –
4-Chapter 297
5-(House Bill 1148)
62
7-AN ACT concerning
3+EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
4+ [Brackets] indicate matter deleted from existing law.
5+ Underlining indicates amendments to bill.
6+ Strike out indicates matter stricken from the bill by amendment or deleted from the law by
7+amendment.
8+ *hb1148*
89
9-Health Insurance – Two–Sided Incentive Arrangements and Capitated
10-Payments – Authorization
10+HOUSE BILL 1148
11+J5 2lr1705
12+ CF SB 834
13+By: Delegates Pendergrass, Cullison, and Kipke Kipke, Bagnall, Belcastro,
14+Bhandari, Carr, Chisholm, Hill, Johnson, Kaiser, Kelly, Kerr, Krebs, Landis,
15+R. Lewis, Morgan, Reilly, Rosenberg, Saab, Szeliga, and K. Young
16+Introduced and read first time: February 11, 2022
17+Assigned to: Health and Government Operations
18+Committee Report: Favorable with amendments
19+House action: Adopted
20+Read second time: March 7, 2022
1121
12-FOR the purpose of providing that value–based arrangements established under certain
13-provisions of federal law are exempt from certain provisions of State law regulating
14-health care practitioner referrals; providing that a health care practitioner or set of
15-health care practitioners that accepts capitated payments in a certain manner but
16-does not perform certain other acts is not considered to be performing acts of an
17-insurance business; authorizing certain bonus or incentive–based compensation to
18-include a two–sided incentive arrangement through which a carrier may recoup
19-funds paid to an eligible provider in accordance with a written contract that includes
20-certain requirements; prohibiting a carrier from requiring participation in a carrier’s
21-bonus or incentive–based compensation or two–sided incentive arrangement
22-program or reducing a fee schedule based on nonparticipation; prohibiting
23-participation in a two–sided incentive arrangement from being the sole opportunity
24-for increases in reimbursement; and generally relating to health insurance,
25-two–sided incentive arrangements, and capitated payments.
22+CHAPTER ______
2623
27-BY repealing and reenacting, with amendments,
28- Article – Health Occupations
29-Section 1–302(d)(12)
30- Annotated Code of Maryland
31- (2021 Replacement Volume)
24+AN ACT concerning 1
3225
33-BY repealing and reenacting, with amendments,
34- Article – Insurance
35-Section 4–205(a), 15–113, and 15–1008(b)
36- Annotated Code of Maryland
37- (2017 Replacement Volume and 2021 Supplement)
26+Health Insurance – Two–Sided Incentive Arrangements and Capitated 2
27+Payments – Authorization 3
3828
39-BY repealing and reenacting, without amendments,
40- Article – Insurance
41-Section 4–205(b) and (c) and 15–1008(c)
42- Annotated Code of Maryland
43- (2017 Replacement Volume and 2021 Supplement)
29+FOR the purpose of providing that value–based arrangements established under certain 4
30+provisions of federal law are exempt from certain provisions of State law regulating 5
31+health care practitioner referrals; providing that a health care practitioner or set of 6
32+health care practitioners that accepts capitated payments in a certain manner but 7
33+does not perform certain other acts is not considered to be performing acts of an 8
34+insurance business; authorizing certain bonus or incentive–based compensation to 9
35+include a two–sided incentive arrangement through which a carrier may recoup 10
36+funds paid to an eligible provider in accordance with a written contract that includes 11
37+certain requirements; prohibiting a carrier from requiring participation in a carrier’s 12
38+bonus or incentive–based compensation or two–sided incentive arrangement 13
39+program or reducing a fee schedule based on nonparticipation; prohibiting 14
40+participation in a two–sided incentive arrangement from being the sole opportunity 15
41+for increases in reimbursement; and generally relating to health insurance, 16
42+two–sided incentive arrangements, and capitated payments. 17
4443
45-BY adding to
46- Article – Insurance
47-Section 15–2101 and 15–2102 to be under the new subtitle “Subtitle 21. Capitated
48-Payments”
49- Annotated Code of Maryland Ch. 297 2022 LAWS OF MARYLAND
44+BY repealing and reenacting, with amendments, 18
45+ Article – Health Occupations 19
46+Section 1–302(d)(12) 20
47+ Annotated Code of Maryland 21
48+ (2021 Replacement Volume) 22 2 HOUSE BILL 1148
5049
51-– 2 –
52- (2017 Replacement Volume and 2021 Supplement)
5350
54-Preamble
5551
56-WHEREAS, Value–based care is a health care practitioner payment structure that
57-ties practitioner revenue to improved health outcomes and the value of services delivered
58-rather than the volume of services provided; and
52+BY repealing and reenacting, with amendments, 1
53+ Article – Insurance 2
54+Section 4–205(a), 15–113, and 15–1008(b) 3
55+ Annotated Code of Maryland 4
56+ (2017 Replacement Volume and 2021 Supplement) 5
5957
60-WHEREAS, Value–based arrangements may help to reduce disparities, expand
61-access to care, and improve outcomes, quality, and affordability; and
58+BY repealing and reenacting, without amendments, 6
59+ Article – Insurance 7
60+Section 4–205(b) and (c) and 15–1008(c) 8
61+ Annotated Code of Maryland 9
62+ (2017 Replacement Volume and 2021 Supplement) 10
6263
63-WHEREAS, Value–based care models promote the Triple Aim framework used by
64-the Centers for Medicare and Medicaid Services to optimize health care systems through
65-better care and experience for individuals, better health for populations, and lower per
66-capita costs with demonstrated improvements in quality, cost–savings, and better
67-management of chronic illnesses; and
64+BY adding to 11
65+ Article – Insurance 12
66+Section 15–2101 and 15–2102 to be under the new subtitle “Subtitle 21. Capitated 13
67+Payments” 14
68+ Annotated Code of Maryland 15
69+ (2017 Replacement Volume and 2021 Supplement) 16
6870
69-WHEREAS, Value–based care models continue to show promising results and
70-expand throughout the rest of the country and in Medicare and Medicaid, with broad
71-support from both public and private stakeholders; and
71+Preamble 17
7272
73- WHEREAS, Hospitals, health care practitioners, and payers should be allowed to
74-voluntarily participate in patient–focused, outcome–driven, value–based reimbursement
75-arrangements in Maryland’s commercial insurance markets that seek to align with
76-value–based programs under Maryland’s Total Cost of Care model and ensure that
77-practitioners have adequate contract protections and that consumers continue to have
78-access to high–quality care that promotes better health outcomes; and
73+WHEREAS, Value–based care is a health care practitioner payment structure that 18
74+ties practitioner revenue to improved health outcomes and the value of services delivered 19
75+rather than the volume of services provided; and 20
7976
80- WHEREAS, Maryland has unique statutory barriers precluding commercial payers
81-from entering into certain value–based care arrangements outside of Maryland’s Total Cost
82-of Care model compared to other states in the nation; and
77+WHEREAS, Value–based arrangements may help to reduce disparities, expand 21
78+access to care, and improve outcomes, quality, and affordability; and 22
8379
84- WHEREAS, In Maryland, changes are needed to the health care practitioner bonus
85-and other compensation provisions applicable to the commercial market to allow
86-practitioners to enter into both two–sided incentive and capitation arrangements with
87-commercial plans as they do in other states and the Medicare and Medicaid segments; now,
88-therefore,
80+WHEREAS, Value–based care models promote the Triple Aim framework used by 23
81+the Centers for Medicare and Medicaid Services to optimize health care systems through 24
82+better care and experience for individuals, better health for populations, and lower per 25
83+capita costs with demonstrated improvements in quality, cost–savings, and better 26
84+management of chronic illnesses; and 27
8985
90- SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND,
91-That the Laws of Maryland read as follows:
86+WHEREAS, Value–based care models continue to show promising results and 28
87+expand throughout the rest of the country and in Medicare and Medicaid, with broad 29
88+support from both public and private stakeholders; and 30
9289
93-Article – Health Occupations
90+ WHEREAS, Hospitals, health care practitioners, and payers should be allowed to 31
91+voluntarily participate in patient–focused, outcome–driven, value–based reimbursement 32
92+arrangements in Maryland’s commercial insurance markets that seek to align with 33
93+value–based programs under Maryland’s Total Cost of Care model and ensure that 34
94+practitioners have adequate contract protections and that consumers continue to have 35
95+access to high–quality care that promotes better health outcomes; and 36
96+ HOUSE BILL 1148 3
9497
95-1–302.
9698
97- (d) The provisions of this section do not apply to: LAWRENCE J. HOGAN, JR., Governor Ch. 297
99+ WHEREAS, Maryland has unique statutory barriers precluding commercial payers 1
100+from entering into certain value–based care arrangements outside of Maryland’s Total Cost 2
101+of Care model compared to other states in the nation; and 3
98102
99-– 3 –
103+ WHEREAS, In Maryland, changes are needed to the health care practitioner bonus 4
104+and other compensation provisions applicable to the commercial market to allow 5
105+practitioners to enter into both two–sided incentive and capitation arrangements with 6
106+commercial plans as they do in other states and the Medicare and Medicaid segments; now, 7
107+therefore, 8
100108
101- (12) Subject to subsection (f) of this section, a health care practitioner who
102-has a compensation arrangement with a health care entity, if the compensation
103-arrangement is funded by or paid under:
109+ SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 9
110+That the Laws of Maryland read as follows: 10
104111
105- (i) A Medicare shared savings program accountable care
106-organization authorized under 42 U.S.C. § 1395jjj;
112+Article – Health Occupations 11
107113
108- (ii) As authorized under 42 U.S.C. § 1315a:
114+1–302. 12
109115
110- 1. An advance payment accountable care organization
111-model;
116+ (d) The provisions of this section do not apply to: 13
112117
113- 2. A pioneer accountable care organization model; or
118+ (12) Subject to subsection (f) of this section, a health care practitioner who 14
119+has a compensation arrangement with a health care entity, if the compensation 15
120+arrangement is funded by or paid under: 16
114121
115- 3. A next generation accountable care organization model;
122+ (i) A Medicare shared savings program accountable care 17
123+organization authorized under 42 U.S.C. § 1395jjj; 18
116124
117- (iii) An alternative payment model approved by the federal Centers
118-for Medicare and Medicaid Services; [or]
125+ (ii) As authorized under 42 U.S.C. § 1315a: 19
119126
120- (iv) Another model approved by the federal Centers for Medicare and
121-Medicaid Services that may be applied to health care services provided to both Medicare
122-beneficiaries and individuals who are not Medicare beneficiaries; OR
127+ 1. An advance payment accountable care organization 20
128+model; 21
123129
124- (V) A VALUE–BASED ARRANGEMENT TH AT MEETS THE
125-REQUIREMENTS OF 42 C.F.R. § 411.357(AA)(1) THROUGH (3).
130+ 2. A pioneer accountable care organization model; or 22
126131
127-Article – Insurance
132+ 3. A next generation accountable care organization model; 23
128133
129-4–205.
134+ (iii) An alternative payment model approved by the federal Centers 24
135+for Medicare and Medicaid Services; [or] 25
130136
131- (a) This section does not apply to:
137+ (iv) Another model approved by the federal Centers for Medicare and 26
138+Medicaid Services that may be applied to health care services provided to both Medicare 27
139+beneficiaries and individuals who are not Medicare beneficiaries; OR 28
132140
133- (1) the lawful transaction of surplus lines insurance;
141+ (V) A VALUE–BASED ARRANGEMENT TH AT MEETS THE 29
142+REQUIREMENTS OF 42 C.F.R. § 411.357(AA)(1) THROUGH (3). 30
134143
135- (2) the lawful transaction of reinsurance by insurers;
144+Article – Insurance 31
145+ 4 HOUSE BILL 1148
136146
137- (3) transactions in the State that involve, and are subsequent to the
138-issuance of, a policy that was lawfully solicited, written, and delivered outside of the State
139-covering only a subject of insurance not resident, located, or expressly to be performed in
140-the State at the time of issuance of the policy;
141147
142- (4) transactions that involve insurance contracts that are independently
143-procured through negotiations occurring entirely outside of the State and that are reported
144-and on which the premium tax is paid in accordance with §§ 4–210 and 4–211 of this
145-subtitle; Ch. 297 2022 LAWS OF MARYLAND
148+4–205. 1
146149
147-– 4 –
150+ (a) This section does not apply to: 2
148151
149- (5) an attorney while acting in the ordinary relation of attorney and client
150-in the adjustment of claims or losses; [or]
152+ (1) the lawful transaction of surplus lines insurance; 3
151153
152- (6) unless otherwise determined by the Commissioner, transactions in the
153-State that involve group or blanket insurance or group annuities if the master policy of the
154-group was lawfully issued and delivered in another state in which the person was
155-authorized to engage in insurance business; OR
154+ (2) the lawful transaction of reinsurance by insurers; 4
156155
157- (7) A HEALTH CARE PRACTI TIONER OR SET OF HEA LTH CARE
158-PRACTITIONERS , AS DEFINED IN § 15–113 OF THIS ARTICLE , THAT ACCEPTS
159-CAPITATED PAYMENTS I N ACCORDANCE WITH § 15–2102 OF THIS ARTICLE , BUT
160-PERFORMS NO OTHER AC TS CONSIDERED ACTS O F AN INSURANCE BUSIN ESS.
156+ (3) transactions in the State that involve, and are subsequent to the 5
157+issuance of, a policy that was lawfully solicited, written, and delivered outside of the State 6
158+covering only a subject of insurance not resident, located, or expressly to be performed in 7
159+the State at the time of issuance of the policy; 8
161160
162- (b) An insurer or other person may not, directly or indirectly, do any of the acts
163-of an insurance business set forth in subsection (c) of this section, except as provided by
164-and in accordance with the specific authorization of statute.
161+ (4) transactions that involve insurance contracts that are independently 9
162+procured through negotiations occurring entirely outside of the State and that are reported 10
163+and on which the premium tax is paid in accordance with §§ 4–210 and 4–211 of this 11
164+subtitle; 12
165165
166- (c) Any of the following acts in the State, effected by mail or otherwise, is
167-considered to be doing an insurance business in the State:
166+ (5) an attorney while acting in the ordinary relation of attorney and client 13
167+in the adjustment of claims or losses; [or] 14
168168
169- (1) making or proposing to make, as an insurer, an insurance contract;
169+ (6) unless otherwise determined by the Commissioner, transactions in the 15
170+State that involve group or blanket insurance or group annuities if the master policy of the 16
171+group was lawfully issued and delivered in another state in which the person was 17
172+authorized to engage in insurance business; OR 18
170173
171- (2) making or proposing to make, as guarantor or surety insurer, a contract
172-of guaranty or suretyship as a vocation and not merely incidental to another legitimate
173-business or activity of the guarantor or surety insurer;
174+ (7) A HEALTH CARE PRACTI TIONER OR SET OF HEA LTH CARE 19
175+PRACTITIONERS , AS DEFINED IN § 15–113 OF THIS ARTICLE , THAT ACCEPTS 20
176+CAPITATED PAYMENTS I N ACCORDANCE WITH § 15–2102 OF THIS ARTICLE , BUT 21
177+PERFORMS NO OTHER AC TS CONSIDERED ACTS O F AN INSURANCE BUSIN ESS. 22
174178
175- (3) taking or receiving an application for insurance;
179+ (b) An insurer or other person may not, directly or indirectly, do any of the acts 23
180+of an insurance business set forth in subsection (c) of this section, except as provided by 24
181+and in accordance with the specific authorization of statute. 25
176182
177- (4) receiving or collecting premiums, commissions, membership fees,
178-assessments, dues, or other consideration for insurance;
183+ (c) Any of the following acts in the State, effected by mail or otherwise, is 26
184+considered to be doing an insurance business in the State: 27
179185
180- (5) issuing or delivering an insurance contract to a resident of the State or
181-a person authorized to do business in the State;
186+ (1) making or proposing to make, as an insurer, an insurance contract; 28
182187
183- (6) except as provided in subsection (d) of this section, with respect to a
184-subject of insurance resident, located, or to be performed in the State, directly or indirectly
185-acting as an insurance producer for, or otherwise representing or helping on behalf of
186-another, an insurer or other person to:
188+ (2) making or proposing to make, as guarantor or surety insurer, a contract 29
189+of guaranty or suretyship as a vocation and not merely incidental to another legitimate 30
190+business or activity of the guarantor or surety insurer; 31
187191
188- (i) solicit, negotiate, procure, or effect insurance or the renewal of
189-insurance;
192+ (3) taking or receiving an application for insurance; 32
193+ HOUSE BILL 1148 5
190194
191- (ii) disseminate information about coverage or rates;
192195
193- (iii) forward an application; LAWRENCE J. HOGAN, JR., Governor Ch. 297
196+ (4) receiving or collecting premiums, commissions, membership fees, 1
197+assessments, dues, or other consideration for insurance; 2
194198
195-– 5 –
199+ (5) issuing or delivering an insurance contract to a resident of the State or 3
200+a person authorized to do business in the State; 4
196201
197- (iv) deliver a policy or insurance contract;
202+ (6) except as provided in subsection (d) of this section, with respect to a 5
203+subject of insurance resident, located, or to be performed in the State, directly or indirectly 6
204+acting as an insurance producer for, or otherwise representing or helping on behalf of 7
205+another, an insurer or other person to: 8
198206
199- (v) inspect risks;
207+ (i) solicit, negotiate, procure, or effect insurance or the renewal of 9
208+insurance; 10
200209
201- (vi) fix rates;
210+ (ii) disseminate information about coverage or rates; 11
202211
203- (vii) investigate or adjust claims or losses;
212+ (iii) forward an application; 12
204213
205- (viii) transact matters arising out of an insurance contract after the
206-insurance contract becomes effective; or
214+ (iv) deliver a policy or insurance contract; 13
207215
208- (ix) in any other manner represent or help an insurer or other person
209-to transact insurance business;
216+ (v) inspect risks; 14
210217
211- (7) doing any kind of insurance business specifically recognized as doing
212-an insurance business under statutes relating to insurance;
218+ (vi) fix rates; 15
213219
214- (8) doing or proposing to do any insurance business that is substantially
215-equivalent to any act listed in this subsection in a manner designed to evade the statutes
216-relating to insurance; or
220+ (vii) investigate or adjust claims or losses; 16
217221
218- (9) as an insurer transacting any other business in the State.
222+ (viii) transact matters arising out of an insurance contract after the 17
223+insurance contract becomes effective; or 18
219224
220-15–113.
225+ (ix) in any other manner represent or help an insurer or other person 19
226+to transact insurance business; 20
221227
222- (a) (1) In this section the following words have the meanings indicated.
228+ (7) doing any kind of insurance business specifically recognized as doing 21
229+an insurance business under statutes relating to insurance; 22
223230
224- (2) “Carrier” means:
231+ (8) doing or proposing to do any insurance business that is substantially 23
232+equivalent to any act listed in this subsection in a manner designed to evade the statutes 24
233+relating to insurance; or 25
225234
226- (i) an insurer;
235+ (9) as an insurer transacting any other business in the State. 26
227236
228- (ii) a nonprofit health service plan;
237+15–113. 27
229238
230- (iii) a health maintenance organization;
239+ (a) (1) In this section the following words have the meanings indicated. 28
231240
232- (iv) a dental plan organization; or
241+ (2) “Carrier” means: 29
242+ 6 HOUSE BILL 1148
233243
234- (v) any other person that provides health benefit plans subject to
235-regulation by the State.
236244
237- (3) “ELIGIBLE PROVIDER ” MEANS:
245+ (i) an insurer; 1
238246
239- (I) A LICENSED PHYSICIAN , AS DEFINED IN § 14–101 OF THE
240-HEALTH OCCUPATIONS ARTICLE, WHO VOLUNTARILY PART ICIPATES IN A
241-TWO–SIDED INCENTIVE ARRA NGEMENT; OR Ch. 297 2022 LAWS OF MARYLAND
247+ (ii) a nonprofit health service plan; 2
242248
243-– 6 –
249+ (iii) a health maintenance organization; 3
244250
245- (II) A SET OF HEALTH CARE PRACTITIONERS THAT
246-VOLUNTARILY PARTICIP ATE IN A TWO–SIDED INCENTIVE ARRA NGEMENT.
251+ (iv) a dental plan organization; or 4
247252
248- [(3)] (4) “Health care practitioner” means an individual who is licensed,
249-certified, or otherwise authorized under the Health Occupations Article to provide health
250-care services.
253+ (v) any other person that provides health benefit plans subject to 5
254+regulation by the State. 6
251255
252- (5) “SET OF HEALTH CARE PR ACTITIONERS” MEANS:
256+ (3) “ELIGIBLE PROVIDER ” MEANS: 7
253257
254- (I) A GROUP PRACTICE ;
258+ (I) A LICENSED PHYSICIAN , AS DEFINED IN § 14–101 OF THE 8
259+HEALTH OCCUPATIONS ARTICLE, WHO VOLUNTARILY PARTICIPATES IN A 9
260+TWO–SIDED INCENTIVE ARRA NGEMENT; OR 10
255261
256- (II) A CLINICALLY INTEGRA TED ORGANIZATION EST ABLISHED
257-IN ACCORDANCE WITH SUBTITLE 19 OF THIS TITLE;
262+ (II) A SET OF HEALTH CARE PRACTITIONERS THAT 11
263+VOLUNTARILY PARTICIP ATE IN A TWO–SIDED INCENTIVE ARRA NGEMENT. 12
258264
259- (III) AN ACCOUNTABLE CARE ORGANIZATION ESTABLI SHED IN
260-ACCORDANCE WITH 42 U.S.C. § 1395JJJ AND ANY APPLICAB LE FEDERAL
261-REGULATIONS ; OR
265+ [(3)] (4) “Health care practitioner” means an individual who is licensed, 13
266+certified, or otherwise authorized under the Health Occupations Article to provide health 14
267+care services. 15
262268
263- (IV) A CLINICALLY INTEGRA TED NETWORK THAT IS A PROVIDER
264-ENTITY THAT MEETS TH E CRITERIA ESTABLISH ED IN GUIDANCE ISSUED BY T HE
265-FEDERAL TRADE COMMISSION, INCLUDING A NETWORK OF BEHAVIORAL HEALTH
266-CARE PROGRAMS LICENS ED UNDER § 7.5–401 OF THE HEALTH – GENERAL ARTICLE.
269+ (5) “SET OF HEALTH CARE PR ACTITIONERS” MEANS: 16
267270
268- (6) “TWO–SIDED INCENTIVE ARRA NGEMENT” MEANS AN
269-ARRANGEMENT BETWEEN AN ELIGIBLE PROVIDER AND A CARRIER IN WHICH T HE
270-ELIGIBLE PROVIDER MA Y EARN AN INCENTIVE AND A CARRIER MAY RE COUP FUNDS
271-FROM THE ELIGIBLE PR OVIDER IN ACCORDANCE WITH THE TERMS OF A CONTRACT
272-ENTERED INTO WITH TH E ELIGIBLE PROVIDER THAT MEETS THE REQUI REMENTS OF
273-THIS SECTION.
271+ (I) A GROUP PRACTICE ; 17
274272
275- (b) A carrier may not reimburse a health care practitioner in an amount less than
276-the sum or rate negotiated in the carrier’s provider contract with the health care
277-practitioner.
273+ (II) A CLINICALLY INTEGRA TED ORGANIZATION EST ABLISHED 18
274+IN ACCORDANCE WITH SUBTITLE 19 OF THIS TITLE; 19
278275
279- (c) (1) [In this subsection, “set of health care practitioners” means:
276+ (III) AN ACCOUNTABLE CARE ORGANIZATION ESTABLI SHED IN 20
277+ACCORDANCE WITH 42 U.S.C. § 1395JJJ AND ANY APPLICAB LE FEDERAL 21
278+REGULATIONS ; OR 22
280279
281- (i) a group practice;
280+ (IV) A CLINICALLY INTEGRA TED NETWORK THAT IS A PROVIDER 23
281+ENTITY THAT MEETS TH E CRITERIA ESTABLISH ED IN GUIDANCE ISSUED B Y THE 24
282+FEDERAL TRADE COMMISSION, INCLUDING A NETWORK OF BEHAVIORAL HEALTH 25
283+CARE PROGRAMS LICENS ED UNDER § 7.5–401 OF THE HEALTH – GENERAL ARTICLE. 26
282284
283- (ii) a clinically integrated organization established in accordance
284-with Subtitle 19 of this title; or
285+ (6) “TWO–SIDED INCENTIVE ARRA NGEMENT” MEANS AN 27
286+ARRANGEMENT BETWEEN AN ELIGIBLE PROVIDER AND A CARRIER IN WHI CH THE 28
287+ELIGIBLE PROVIDER MA Y EARN AN INCENTIVE AND A CARRIER MAY RE COUP FUNDS 29
288+FROM THE ELIGIBLE PR OVIDER IN ACCORDANCE WITH THE TERMS OF A CONTRACT 30 HOUSE BILL 1148 7
285289
286- (iii) an accountable care organization established in accordance with
287-42 U.S.C. § 1395jjj and any applicable federal regulations. LAWRENCE J. HOGAN, JR., Governor Ch. 297
288290
289-– 7 –
291+ENTERED INTO WITH TH E ELIGIBLE PROVIDER THAT MEETS THE REQUI REMENTS OF 1
292+THIS SECTION. 2
290293
291- (2)] This section does not prohibit a carrier from:
294+ (b) A carrier may not reimburse a health care practitioner in an amount less than 3
295+the sum or rate negotiated in the carrier’s provider contract with the health care 4
296+practitioner. 5
292297
293- (I) providing bonuses or other incentive–based compensation to a
294-health care practitioner or a set of health care practitioners [if the bonus or other
295-incentive–based compensation:]; OR
298+ (c) (1) [In this subsection, “set of health care practitioners” means: 6
296299
297- (II) ENTERING INTO A TWO –SIDED INCENTIVE ARRA NGEMENT
298-WITH AN ELIGIBLE PRO VIDER.
300+ (i) a group practice; 7
299301
300- (2) A BONUS OR OTHER INCEN TIVE–BASED COMPENSATION
301-PROGRAM OR TWO –SIDED INCENTIVE ARRA NGEMENT AUTHORIZED U NDER THIS
302-SECTION:
302+ (ii) a clinically integrated organization established in accordance 8
303+with Subtitle 19 of this title; or 9
303304
304- (i) [does] MAY not create a disincentive to the provision of medically
305-appropriate or medically necessary health care services; and
305+ (iii) an accountable care organization established in accordance with 10
306+42 U.S.C. § 1395jjj and any applicable federal regulations. 11
306307
307- (ii) if the carrier is a health maintenance organization, [complies]
308-SHALL COMPLY with the provisions of § 19–705.1 of the Health – General Article.
308+ (2)] This section does not prohibit a carrier from: 12
309309
310- (3) A bonus or other incentive–based compensation OR TWO–SIDED
311-INCENTIVE ARRANGEMEN T AUTHORIZED under this [subsection] SECTION:
310+ (I) providing bonuses or other incentive–based compensation to a 13
311+health care practitioner or a set of health care practitioners [if the bonus or other 14
312+incentive–based compensation:]; OR 15
312313
313- (i) if applicable, shall promote HEALTH EQUITY , IMPROVEMENT
314-OF HEALTH CARE OUTCO MES, AND the provision of preventive health care services; or
314+ (II) ENTERING INTO A TWO –SIDED INCENTIVE ARRA NGEMENT 16
315+WITH AN ELIGIBLE PRO VIDER. 17
315316
316- (ii) may reward a health care practitioner [or], a set of health care
317-practitioners, OR AN ELIGIBLE PROVI DER, based on satisfaction of performance
318-measures, if the following is agreed on in writing by the carrier and the health care
319-practitioner [or], set of health care practitioners, OR ELIGIBLE PROVIDER :
317+ (2) A BONUS OR OTHER INCEN TIVE–BASED COMPENSATION 18
318+PROGRAM OR TWO –SIDED INCENTIVE ARRA NGEMENT AUTHORIZED U NDER THIS 19
319+SECTION: 20
320320
321- 1. the performance measures, INCLUDING THE SOURCE OF
322-THE MEASURES ;
321+ (i) [does] MAY not create a disincentive to the provision of medically 21
322+appropriate or medically necessary health care services; and 22
323323
324- 2. the method AND THE TIME PERIOD for calculating
325-whether the performance measures have been satisfied; [and]
324+ (ii) if the carrier is a health maintenance organization, [complies] 23
325+SHALL COMPLY with the provisions of § 19–705.1 of the Health – General Article. 24
326326
327- 3. the method by which the health care practitioner [or], set
328-of health care practitioners, OR ELIGIBLE PROVIDER may request reconsideration of the
329-calculations by the carrier; AND
327+ (3) A bonus or other incentive–based compensation OR TWO–SIDED 25
328+INCENTIVE ARRANGEMEN T AUTHORIZED under this [subsection] SECTION: 26
330329
331- 4. IF APPLICABLE , THE RISK–ADJUSTMENT METHOD
332-USED.
333- Ch. 297 2022 LAWS OF MARYLAND
330+ (i) if applicable, shall promote HEALTH EQUITY , IMPROVEMENT 27
331+OF HEALTH CARE OUTCO MES, AND the provision of preventive health care services; or 28
334332
335-– 8 –
336- (4) Acceptance of a bonus or other incentive–based compensation OR
337-TWO–SIDED INCENTIVE ARRA NGEMENT under this subsection shall be voluntary.
333+ (ii) may reward a health care practitioner [or], a set of health care 29
334+practitioners, OR AN ELIGIBLE PROVI DER, based on satisfaction of performance 30 8 HOUSE BILL 1148
338335
339- (5) A CARRIER MAY NOT REDU CE THE FEE SCHEDULE OF A HEALTH
340-CARE PRACTITIONER , OR A SET OF HEALTH CARE P RACTITIONERS , OR AN ELIGIBLE
341-PROVIDER SOLELY BECAUSE THE HEALTH C ARE PRACTITIONER , OR SET OF HEALTH
342-CARE PRACTITIONERS , OR ELIGIBLE PROVIDER DOES NOT PARTICIPATE IN THE
343-CARRIER’S BONUS OR OTHER INC ENTIVE–BASED COMPENSATION O R TWO–SIDED
344-INCENTIVE ARRANGEMEN T PROGRAM.
345336
346- (6) PARTICIPATION IN A TW O–SIDED INCENTIVE ARRA NGEMENT MAY
347-NOT BE THE SOLE OPPO RTUNITY FOR A HEALTH CARE PRACTITIONER OR A SET OF
348-HEALTH CARE PRACTITI ONERS TO BE ELIGIBLE TO RECEIVE INCREASES IN
349-REIMBURSEMENT .
337+measures, if the following is agreed on in writing by the carrier and the health care 1
338+practitioner [or], set of health care practitioners, OR ELIGIBLE PROVIDER : 2
350339
351- [(5)] (6) (7) A carrier may not require [a health care practitioner or a set of
352-health care practitioners to participate in the carrier’s bonus or incentive–based
353-compensation program] as a condition of participation in the carrier’s provider network:
340+ 1. the performance measures, INCLUDING THE SOURCE OF 3
341+THE MEASURES ; 4
354342
355- (I) A HEALTH CARE PRACTI TIONER OR SET OF HEA LTH CARE
356-PRACTITIONERS TO PAR TICIPATE IN THE CARR IER’S BONUS OR OTHER
357-INCENTIVE–BASED COMPENSATION P ROGRAM; OR
343+ 2. the method AND THE TIME PERIOD for calculating 5
344+whether the performance measures have been satisfied; [and] 6
358345
359- (II) AN ELIGIBLE PROVIDER TO PARTICIPATE IN TH E CARRIER’S
360-TWO–SIDED INCENTIVE ARRA NGEMENT PROGRAM .
346+ 3. the method by which the health care practitioner [or], set 7
347+of health care practitioners, OR ELIGIBLE PROVIDER may request reconsideration of the 8
348+calculations by the carrier; AND 9
361349
362- [(6)] (7) (8) A health care practitioner, a set of health care practitioners, AN
363-ELIGIBLE PROVIDER , a health care practitioner’s designee, [or] a designee of a set of
364-health care practitioners, OR A DESIGNEE OF AN ELIGIBLE PROVIDER may file a
365-complaint with the Administration regarding a violation of this subsection.
350+ 4. IF APPLICABLE , THE RISK–ADJUSTMENT METHOD 10
351+USED. 11
366352
367- (d) (1) A carrier shall provide a health care practitioner, A SET OF HEALTH
368-CARE PRACTITIONERS , OR AN ELIGIBLE PROVI DER with a copy of:
353+ (4) Acceptance of a bonus or other incentive–based compensation OR 12
354+TWO–SIDED INCENTIVE ARRA NGEMENT under this subsection shall be voluntary. 13
369355
370- (i) a schedule of ALL applicable fees [for up to] OR the [fifty] 50
371-most common services billed by a health care practitioner in that specialty, WHICHEVER
372-IS LESS;
356+ (5) A CARRIER MAY NOT REDU CE THE FEE SCHEDULE OF A HEALTH 14
357+CARE PRACTITIONER , OR A SET OF HEALTH CARE PRACTITIONERS , OR AN ELIGIBLE 15
358+PROVIDER SOLELY BECAUSE THE HEALTH C ARE PRACTITIONER , OR SET OF HEALTH 16
359+CARE PRACTITIONERS , OR ELIGIBLE PROVIDER DOES NOT PARTICIPATE IN THE 17
360+CARRIER’S BONUS OR OTHER INC ENTIVE–BASED COMPENSATION O R TWO–SIDED 18
361+INCENTIVE ARRANGEMEN T PROGRAM. 19
373362
374- (ii) a description of the coding guidelines used by the carrier that are
375-applicable to the services billed by a health care practitioner in that specialty; [and]
363+ (6) PARTICIPATION IN A TW O–SIDED INCENTIVE ARRA NGEMENT MAY 20
364+NOT BE THE SOLE OPPO RTUNITY FOR A HEALTH CARE PRACTITIONER OR A SET OF 21
365+HEALTH CARE PRACTITI ONERS TO BE ELIGIBLE TO RECEIVE INCREASES IN 22
366+REIMBURSEMENT . 23
376367
377- (iii) the information about the practitioner and the methodology that
378-the carrier uses to determine whether to:
379- LAWRENCE J. HOGAN, JR., Governor Ch. 297
368+ [(5)] (6) (7) A carrier may not require [a health care practitioner or a set of 24
369+health care practitioners to participate in the carrier’s bonus or incentive–based 25
370+compensation program] as a condition of participation in the carrier’s provider network: 26
380371
381-– 9 –
382- 1. increase or reduce the practitioner’s level of
383-reimbursement; [and]
372+ (I) A HEALTH CARE PRACTI TIONER OR SET OF HE ALTH CARE 27
373+PRACTITIONERS TO PAR TICIPATE IN THE CARR IER’S BONUS OR OTHER 28
374+INCENTIVE–BASED COMPENSATION P ROGRAM; OR 29
384375
385- 2. provide a bonus or other incentive–based compensation to
386-the practitioner; AND
376+ (II) AN ELIGIBLE PROVIDER TO PARTICIPATE IN TH E CARRIER’S 30
377+TWO–SIDED INCENTIVE ARRA NGEMENT PROGRAM . 31
387378
388- 3. RECOUP COMPENSATION FROM AN ELIGIBLE
389-PROVIDER UNDER A TWO –SIDED INCENTIVE ARRA NGEMENT; AND
379+ [(6)] (7) (8) A health care practitioner, a set of health care practitioners, AN 32
380+ELIGIBLE PROVIDER , a health care practitioner’s designee, [or] a designee of a set of 33 HOUSE BILL 1148 9
390381
391- (IV) A SUMMARY OF THE TER MS OF A TWO –SIDED INCENTIVE
392-ARRANGEMENT PROGRAM .
393382
394- (2) Except as provided in paragraph (4) of this subsection, a carrier shall
395-provide the information required under paragraph (1) of this subsection in the manner
396-indicated in each of the following instances:
383+health care practitioners, OR A DESIGNEE OF AN ELIGIBLE PROVIDER may file a 1
384+complaint with the Administration regarding a violation of this subsection. 2
397385
398- (i) in writing [at the time of] BEFORE A contract execution;
386+ (d) (1) A carrier shall provide a health care practitioner, A SET OF HEALTH 3
387+CARE PRACTITIONERS , OR AN ELIGIBLE PROVI DER with a copy of: 4
399388
400- (ii) in writing or electronically 30 days [prior to] BEFORE a change;
401-and
389+ (i) a schedule of ALL applicable fees [for up to] OR the [fifty] 50 5
390+most common services billed by a health care practitioner in that specialty, WHICHEVER 6
391+IS LESS; 7
402392
403- (iii) in writing or electronically [upon] ON request of the health care
404-practitioner, SET OF HEALTH CARE P RACTITIONERS , OR ELIGIBLE PROVIDER .
393+ (ii) a description of the coding guidelines used by the carrier that are 8
394+applicable to the services billed by a health care practitioner in that specialty; [and] 9
405395
406- (3) Except as provided in paragraph (4) of this subsection, a carrier shall
407-make the pharmaceutical formulary that the carrier uses available to a health care
408-practitioner, A SET OF HEALTH CARE PRACTITIONERS , OR AN ELIGIBLE PROVI DER
409-electronically.
396+ (iii) the information about the practitioner and the methodology that 10
397+the carrier uses to determine whether to: 11
410398
411- (4) On written request of a health care practitioner, A SET OF HEALTH
412-CARE PRACTITIONERS , OR AN ELIGIBLE PROVI DER, a carrier shall provide the
413-information required under paragraphs (1) and (3) of this subsection in writing.
399+ 1. increase or reduce the practitioner’s level of 12
400+reimbursement; [and] 13
414401
415- (5) The Administration may adopt regulations to carry out the provisions
416-of this subsection.
402+ 2. provide a bonus or other incentive–based compensation to 14
403+the practitioner; AND 15
417404
418- (e) (1) A carrier that compensates health care practitioners OR A SET OF
419-HEALTH CARE PRACTITI ONERS wholly or partly on a capitated basis IN ACCORDANCE
420-WITH § 15–2102 OF THIS ARTICLE may not retain any capitated fee attributable to an
421-enrollee or covered person during an enrollee’s or covered person’s contract year.
405+ 3. RECOUP COMPENSATION FROM AN ELIGIBLE 16
406+PROVIDER UNDER A TWO –SIDED INCENTIVE ARRA NGEMENT; AND 17
422407
423- (2) A carrier is in compliance with paragraph (1) of this subsection if,
424-within 45 days after an enrollee or covered person chooses or obtains health care from a
425-health care practitioner OR A SET OF HEALTH C ARE PRACTITIONERS , the carrier pays
426-to the health care practitioner OR SET OF HEALTH CAR E PRACTITIONERS all accrued but Ch. 297 2022 LAWS OF MARYLAND
408+ (IV) A SUMMARY OF THE TER MS OF A TWO –SIDED INCENTIVE 18
409+ARRANGEMENT PROGRAM . 19
427410
428-– 10 –
429-unpaid capitated fees attributable to that enrollee or person that the health care
430-practitioner OR SET OF HEALTH CAR E PRACTITIONERS would have received had the
431-enrollee or person chosen the health care practitioner OR SET OF HEALTH CAR E
432-PRACTITIONERS at the beginning of the enrollee’s or covered person’s contract year.
411+ (2) Except as provided in paragraph (4) of this subsection, a carrier shall 20
412+provide the information required under paragraph (1) of this subsection in the manner 21
413+indicated in each of the following instances: 22
433414
434- (3) ACCEPTANCE OF A CAPITATED PAYME NT SHALL BE VOLUNTAR Y.
415+ (i) in writing [at the time of] BEFORE A contract execution; 23
435416
436- (F) (1) UNDER A TWO–SIDED INCENTIVE ARRA NGEMENT THAT COMPLIE S
437-WITH THE REQUIREMENT S OF THIS SECTION, A CARRIER MAY RECOUP FUNDS PAID
438-TO AN ELIGIBLE PROVI DER BASED ON THE TER MS OF A WRITTEN CONT RACT
439-BETWEEN THE C ARRIER AND THE ELIGI BLE PROVIDER THAT AT A MINIMUM:
417+ (ii) in writing or electronically 30 days [prior to] BEFORE a change; 24
418+and 25
440419
441- (I) ESTABLISH A TARGET B UDGET FOR:
420+ (iii) in writing or electronically [upon] ON request of the health care 26
421+practitioner, SET OF HEALTH CARE P RACTITIONERS , OR ELIGIBLE PROVIDER . 27
442422
443- 1. THE TOTAL COST OF CA RE OF A POPULATION O F
444-PATIENTS ADJUSTED FO R RISK AND POPULATIO N SIZE; OR
423+ (3) Except as provided in paragraph (4) of this subsection, a carrier shall 28
424+make the pharmaceutical formulary that the carrier uses available to a health care 29
425+practitioner, A SET OF HEALTH CARE PRACTITIONERS , OR AN ELIGIBLE PROVI DER 30
426+electronically. 31
427+ 10 HOUSE BILL 1148
445428
446- 2. THE COST OF AN EPISO DE OF CARE;
447429
448- (II) LIMIT RECOUPME NT TO NOT MORE THAN 50% OF THE
449-EXCESS ABOVE THE MUT UALLY AGREED ON TARG ET ESTABLISHED IN AC CORDANCE
450-WITH ITEM (I) OF THIS PARAGRAPH ;
430+ (4) On written request of a health care practitioner, A SET OF HEALTH 1
431+CARE PRACTITI ONERS, OR AN ELIGIBLE PROVI DER, a carrier shall provide the 2
432+information required under paragraphs (1) and (3) of this subsection in writing. 3
451433
452- (III) SPECIFY A MUTUALLY A GREED ON MAXIMUM LIA BILITY FOR
453-TOTAL RECOUPMENT THA T MAY NOT EXCEED 10% OF THE ANNUAL PAYMEN TS FROM
454-THE CARRIER TO THE E LIGIBLE PROVIDER ;
434+ (5) The Administration may adopt regulations to carry out the provisions 4
435+of this subsection. 5
455436
456- (IV) PROVIDE AN OPPORTUNI TY FOR GAINS BY AN E LIGIBLE
457-PROVIDER THAT IS GRE ATER THAN THE OPPORT UNITY FOR RECOUPMENT BY THE
458-CARRIER;
437+ (e) (1) A carrier that compensates health care practitioners OR A SET OF 6
438+HEALTH CARE PRACTITI ONERS wholly or partly on a capitated basis IN ACCORDANCE 7
439+WITH § 15–2102 OF THIS ARTICLE may not retain any capitated fee attributable to an 8
440+enrollee or covered person during an enrollee’s or covered person’s contract year. 9
459441
460- (V) FOLLOWING GOOD FAITH NEGOTIATIONS , PROVIDE AN
461-OPPORTUNITY FOR AN A UDIT BY AN INDEPENDEN T THIRD PARTY AND AN
462-INDEPENDENT THIRD –PARTY DISPUTE RESOLU TION PROCESS;
442+ (2) A carrier is in compliance with paragraph (1) of this subsection if, 10
443+within 45 days after an enrollee or covered person chooses or obtains health care from a 11
444+health care practitioner OR A SET OF HEALTH C ARE PRACTITIONERS , the carrier pays 12
445+to the health care practitioner OR SET OF HEALTH CAR E PRACTITIONERS all accrued but 13
446+unpaid capitated fees attributable to that enrollee or person that the health care 14
447+practitioner OR SET OF HEALTH CAR E PRACTITIONERS would have received had the 15
448+enrollee or person chosen the health care practitioner OR SET OF HEALTH CAR E 16
449+PRACTITIONERS at the beginning of the enrollee’s or covered person’s contract year. 17
463450
464- (VI) REQUIRE THE CARRIER AND THE ELIGIBLE PRO VIDER TO
465-NEGOTIATE IN GOOD FA ITH ADJUSTMENTS TO T HE TARGET BUDGET WHE N:
451+ (3) ACCEPTANCE OF A CAPIT ATED PAYMENT SHALL B E VOLUNTARY . 18
466452
467- 1. CERTAIN CIRCUMSTANCE S BEYOND THE CONTROL OF
468-THE CARRIER OR THE E LIGIBLE PROVIDER ARI SE, INCLUDING CHANGES IN
469-HOSPITAL RATES ; AND
470- LAWRENCE J. HOGAN, JR., Governor Ch. 297
453+ (F) (1) UNDER A TWO–SIDED INCENTIVE ARRA NGEMENT THAT COMPLIE S 19
454+WITH THE REQUIREMENT S OF THIS SECTION, A CARRIER MAY RECOUP FUNDS PAID 20
455+TO AN ELIGIBLE PROVI DER BASED ON THE TER MS OF A WRITTEN CONT RACT 21
456+BETWEEN THE CARRIER AND THE ELIGIBLE PRO VIDER THAT AT A MINI MUM: 22
471457
472-– 11 –
473- 2. MATERIAL CHANGES OCC UR IN HEALTH CARE
474-ECONOMICS, HEALTH CARE DELIVERY , OR REGULATIONS THAT IMPACT THE
475-ARRANGEMENT ; AND
458+ (I) ESTABLISH A TARGET B UDGET FOR: 23
476459
477- (VII) REQUIRE THE CARRIER TO PAY ANY INCENTIVE TO OR
478-REQUEST ANY RECOUPME NT FROM THE ELIGIBLE PROVIDER WITHIN 6 MONTHS
479-AFTER THE END OF THE CONTRACT YEAR , UNLESS THE CARRIER O R ELIGIBLE
480-PROVIDER INITIATES A DISPUTE RELATING TO THE RECOUPMENT OR IN CENTIVE
481-AMOUNT.
460+ 1. THE TOTAL COST OF CA RE OF A POPULATION O F 24
461+PATIENTS ADJUSTED FO R RISK AND POPULATIO N SIZE; OR 25
482462
483- (2) UNLESS MUTUALL Y AGREED TO BY AN EL IGIBLE PROVIDER AND A
484-CARRIER, AN ARRANGEMENT ENTER ED INTO UNDER THIS S UBSECTION MAY NOT
485-PROVIDE AN OPPORTUNI TY FOR RECOUPMENT BY THE CARRIER BASED ON THE
486-ELIGIBLE PROVIDER ’S PERFORMANCE DURING THE FIRST 12 MONTHS OF THE
487-ARRANGEMENT .
463+ 2. THE COST OF AN EPISO DE OF CARE; 26
488464
489- (3) A CARRIER THAT ENTERS INTO A TWO –SIDED INCENTIVE
490-ARRANGEMENT WITH AN ELIGIBLE PROVIDER IN WHICH THE AMOUNT OF ANY
491-PAYMENT IS DETERMINE D, IN WHOLE OR IN PART , ON THE TOTAL COST OF CARE OF
492-A POPULATION OF PATI ENTS OR AN EPISODE O F CARE, SHALL, AT LEAST
493-QUARTERLY , DISCLOSE TO THE ELIG IBLE PROVIDER THE FO LLOWING INFORMATION
494-IN A MANNER THAT MEE TS FEDERAL AND STATE DATA USE AND PR IVACY
495-STANDARDS:
465+ (II) LIMIT RECOUPMENT TO NOT MORE THAN 50% OF THE 27
466+EXCESS ABOVE THE MUTUALLY AGREED ON T ARGET ESTABLISHED IN ACCORDANCE 28
467+WITH ITEM (I) OF THIS PARAGRAPH ; 29
496468
497- (I) ANY AMOUNT PAID TO A NOTHER HEALTH CARE P ROVIDER
498-THAT IS INCLUDED IN THE TOTAL COST OF CA RE OF A PATIENT IN THE POPULATION
499-OR EPISODE OF CARE ; AND
469+ (III) SPECIFY A MUTUALLY A GREED ON MAXIMUM LIA BILITY FOR 30
470+TOTAL RECOUPMENT THA T MAY NOT EXCEED 10% OF THE ANNUAL PAYMEN TS FROM 31
471+THE CARRIER TO THE E LIGIBLE PROVIDER ; 32
472+ HOUSE BILL 1148 11
500473
501- (II) ANY COPAYMENT , COINSURANCE , OR DEDUCTIBLE THAT I S
502-INCLUDED IN THE TOTA L COST OF CARE OF A PATIENT IN THE POPUL ATION OR
503-EPISODE OF CARE .
504474
505- (4) UNLESS MUTUALLY AGREE D TO BY THE CARRIER AND ELIGIBLE
506-PROVIDER, A TWO–SIDED INCENTIVE ARRA NGEMENT MAY NOT BE A MENDED
507-DURING THE TERM OF T HE CONTRACT .
475+ (IV) PROVIDE AN OPPORTUNI TY FOR GAINS BY AN E LIGIBLE 1
476+PROVIDER THAT IS GRE ATER THAN THE OPPORT UNITY FOR RECOUPMENT BY THE 2
477+CARRIER; 3
508478
509- (5) THE OPPORTUNITY FOR I NDEPENDENT THIRD –PARTY DISPUTE
510-RESOLUTION PROVIDED FOR IN PARAGRAPH (1)(V) OF THIS SUBSECTION MAY NOT
511-BE REQUIRED TO BE EX HAUSTED BEFORE A MEM BER OR MEMBER ’S
512-REPRESENTATIVE IS AL LOWED TO FILE AN APP EAL OF A COVERAGE DE CISION
513-UNDER § 15–10D–02 OF THIS TITLE.
479+ (V) FOLLOWING GOOD FAITH NEGOTIATIONS , PROVIDE AN 4
480+OPPORTUNITY FOR AN A UDIT BY AN INDEPENDE NT THIRD PARTY AND A N 5
481+INDEPENDENT THIRD–PARTY DISPUTE RESOLU TION PROCESS; 6
514482
515- (6) NOTHING IN THIS SUBSE CTION MAY BE CONSTRU ED TO:
516- Ch. 297 2022 LAWS OF MARYLAND
483+ (VI) REQUIRE THE CARRIER AND THE ELIGIBLE PRO VIDER TO 7
484+NEGOTIATE IN GOOD FA ITH ADJUSTMENTS TO T HE TARGET BUDGET WHE N: 8
517485
518-– 12 –
519- (I) ALTER ANY RE QUIREMENT FOR A CARR IER TO PAY A
520-HOSPITAL OR RELATED INSTITUTION THE RATE APPROVED BY THE HEALTH
521-SERVICES COST REVIEW COMMISSION FOR HOSPIT AL SERVICES; OR
486+ 1. CERTAIN CIRCUMSTANCE S BEYOND THE CONTROL OF 9
487+THE CARRIER OR THE E LIGIBLE PROVIDER A RISE, INCLUDING CHANGES IN 10
488+HOSPITAL RATES ; AND 11
522489
523- (II) SUPERSEDE THE HEALTH SERVICES COST REVIEW
524-COMMISSION’S JURISDICTION OR AU THORITY OVER RATE REVIEW AND APPROVAL
525-FOR HOSPITAL SERVICE S.
490+ 2. MATERIAL CHANGES OCC UR IN HEALTH CARE 12
491+ECONOMICS, HEALTH CARE DELIVERY , OR REGULATIONS THAT IMPACT THE 13
492+ARRANGEMENT ; AND 14
526493
527-15–1008.
494+ (VII) REQUIRE THE CARRIER TO PAY ANY INCENTIVE TO OR 15
495+REQUEST ANY RECOUPME NT FROM THE ELIGIBLE PROV IDER WITHIN 6 MONTHS 16
496+AFTER THE END OF THE CONTRACT YEAR , UNLESS THE CARRIER O R ELIGIBLE 17
497+PROVIDER INITIATES A DISPUTE RELATING TO THE RECOUPMENT OR IN CENTIVE 18
498+AMOUNT. 19
528499
529- (b) This section does not apply to an adjustment to reimbursement:
500+ (2) UNLESS MUTUALLY AGREE D TO BY AN ELIGIBLE PROVIDER AND A 20
501+CARRIER, AN ARRANGEMENT ENTER ED INTO UNDER THIS S UBSECTION MAY NOT 21
502+PROVIDE AN OPPORTUNI TY FOR RECOUPMENT BY THE CARRIER BASED ON THE 22
503+ELIGIBLE PROVIDER ’S PERFORMANCE DURING THE FIRST 12 MONTHS OF THE 23
504+ARRANGEMENT . 24
530505
531- (1) made as part of an annual contracted reconciliation of a risk sharing
532-arrangement under an administrative service provider contract; OR
506+ (3) A CARRIER THAT ENTERS INTO A TWO –SIDED INCENTIVE 25
507+ARRANGEMENT WITH AN ELIGIBLE PROVIDER IN WHICH THE AMOUNT OF ANY 26
508+PAYMENT IS DETERMINE D, IN WHOLE OR IN PART , ON THE TOTAL COST OF CARE OF 27
509+A POPULATION OF PATI ENTS OR AN EPISODE O F CARE, SHALL, AT LEAST 28
510+QUARTERLY , DISCLOSE TO THE ELIG IBLE PROVIDER THE FOLLOWING INF ORMATION 29
511+IN A MANNER THAT MEE TS FEDERAL AND STATE DATA USE AND PR IVACY 30
512+STANDARDS: 31
533513
534- (2) MADE AS PART OF A TW O–SIDED INCENTIVE ARRA NGEMENT THAT
535-COMPLIES WITH § 15–113 OF THIS TITLE.
514+ (I) ANY AMOUNT PAID TO A NOTHER HEALTH CARE P ROVIDER 32
515+THAT IS INCLUDED IN THE TOTAL COST OF CA RE OF A PATIENT IN T HE POPULATION 33
516+OR EPISODE OF CARE ; AND 34
517+ 12 HOUSE BILL 1148
536518
537- (c) (1) If a carrier retroactively denies reimbursement to a health care
538-provider, the carrier:
539519
540- (i) may only retroactively deny reimbursement for services subject
541-to coordination of benefits with another carrier, the Maryland Medical Assistance Program,
542-or the Medicare Program during the 18–month period after the date that the carrier paid
543-the health care provider; and
520+ (II) ANY COPAYMENT , COINSURANCE , OR DEDUCTIBLE THAT I S 1
521+INCLUDED IN THE TOTA L COST OF CARE OF A PATIENT IN THE POPUL ATION OR 2
522+EPISODE OF CARE . 3
544523
545- (ii) except as provided in item (i) of this paragraph, may only
546-retroactively deny reimbursement during the 6–month period after the date that the carrier
547-paid the health care provider.
524+ (4) UNLESS MUTUALLY AGREE D TO BY THE CARRIER AND ELIGIBLE 4
525+PROVIDER, A TWO–SIDED INCENTIVE ARRA NGEMENT MAY NOT BE A MENDED 5
526+DURING THE TERM OF T HE CONTRACT . 6
548527
549- (2) (i) A carrier that retroactively denies reimbursement to a health
550-care provider under paragraph (1) of this subsection shall provide the health care provider
551-with a written statement specifying the basis for the retroactive denial.
528+ (5) THE OPPORTUNITY FOR I NDEPENDENT THIRD –PARTY DISPUTE 7
529+RESOLUTION PROVIDED FOR IN PARAGRAPH (1)(V) OF THIS SUBSECTION MAY NOT 8
530+BE REQUIRED TO BE EX HAUSTED BEFORE A MEM BER OR MEMBER ’S 9
531+REPRESENTATIVE IS AL LOWED TO FILE AN APP EAL OF A COVERAGE DE CISION 10
532+UNDER § 15–10D–02 OF THIS TITLE. 11
552533
553- (ii) If the retroactive denial of reimbursement results from
554-coordination of benefits, the written statement shall provide the name and address of the
555-entity acknowledging responsibility for payment of the denied claim.
534+ (6) NOTHING IN THIS SUBSE CTION MAY BE CONSTRU ED TO: 12
556535
557-SUBTITLE 21. CAPITATED PAYMENTS.
536+ (I) ALTER ANY RE QUIREMENT FOR A CARR IER TO PAY A 13
537+HOSPITAL OR RELATED INSTITUTION THE RATE APPROVED BY THE HEALTH 14
538+SERVICES COST REVIEW COMMISSION FOR HOSPIT AL SERVICES; OR 15
558539
559-15–2101.
540+ (II) SUPERSEDE THE HEALTH SERVICES COST REVIEW 16
541+COMMISSION’S JURISDICTION OR AU THORITY OVER RATE REVIEW AND APPROVAL 17
542+FOR HOSPITAL SERVICE S. 18
560543
561- (A) IN THIS SUBTITLE THE FOLLOWING WORDS HAVE THE MEANINGS
562-INDICATED.
563- LAWRENCE J. HOGAN, JR., Governor Ch. 297
544+15–1008. 19
564545
565-– 13 –
566- (B) “ADMINISTRATOR ” MEANS A CARRIER ADMI NISTERING A SELF–FUNDED
567-GROUP HEALTH PLAN .
546+ (b) This section does not apply to an adjustment to reimbursement: 20
568547
569- (C) “CARRIER” HAS THE MEANING STAT ED IN § 15–113 OF THIS TITLE.
548+ (1) made as part of an annual contracted reconciliation of a risk sharing 21
549+arrangement under an administrative service provider contract; OR 22
570550
571- (D) “HEALTH BENEFIT PLAN ” HAS THE MEANING STAT ED IN § 2–112.2 OF
572-THIS ARTICLE.
551+ (2) MADE AS PART OF A TW O–SIDED INCENTIVE ARRA NGEMENT THAT 23
552+COMPLIES WITH § 15–113 OF THIS TITLE. 24
573553
574- (D) (E) “HEALTH CARE PRACTITIO NER” HAS THE MEANING STAT ED IN §
575-15–113 OF THIS TITLE.
554+ (c) (1) If a carrier retroactively denies reimbursement to a health care 25
555+provider, the carrier: 26
576556
577- (E) (F) “MEMBER” HAS THE MEANING STAT ED IN § 15–10A–01 OF THIS
578-TITLE.
557+ (i) may only retroactively deny reimbursement for services subject 27
558+to coordination of benefits with another carrier, the Maryland Medical Assistance Program, 28
559+or the Medicare Program during the 18–month period after the date that the carrier paid 29
560+the health care provider; and 30
579561
580- (F) (G) “NETWORK” HAS THE MEANING STAT ED IN § 15–112 OF THIS
581-TITLE.
562+ (ii) except as provided in item (i) of this paragraph, may only 31
563+retroactively deny reimbursement during the 6–month period after the date that the carrier 32
564+paid the health care provider. 33 HOUSE BILL 1148 13
582565
583- (G) (H) “SET OF HEALTH CARE PR ACTITIONERS” HAS THE MEANING
584-STATED IN § 15–113 OF THIS TITLE.
585566
586- (H) (I) “PARTICIPANT” MEANS AN EMPLOYEE OR AN EMPLOYEE ’S
587-DEPENDENT WHO PARTIC IPATES IN A SELF–FUNDED GROUP HEALTH INSURANCE
588-PLAN.
589567
590-15–2102.
568+ (2) (i) A carrier that retroactively denies reimbursement to a health 1
569+care provider under paragraph (1) of this subsection shall provide the health care provider 2
570+with a written statement specifying the basis for the retroactive denial. 3
591571
592- (A) THIS SECTION APPLIES TO ARRANGEMENTS UNDE R AN INSURED A
593-HEALTH BENEFIT PLAN OFFERED BY A CARRIER OR A SELF–FUNDED GROUP HEALTH
594-INSURANCE PLAN IN WH ICH A CAPITATED PAYM ENT IS:
572+ (ii) If the retroactive denial of reimbursement results from 4
573+coordination of benefits, the written statement shall provide the name and address of the 5
574+entity acknowledging responsibility for payment of the denied claim. 6
595575
596- (1) CALCULATED AS A FIXE D AMOUNT PER MEMBER OR PARTICIPANT
597-ASSIGNED OR ATTRIBUT ED TO THE HEALTH CAR E PRACTITIONER OR SE T OF HEALTH
598-CARE PRACTITIONERS ;
576+SUBTITLE 21. CAPITATED PAYMENTS. 7
599577
600- (2) TO COVER THE PROVISI ON OF A SET OF SERVI CES DEFINED IN THE
601-HEALTH CARE PRACTITI ONER’S OR SET OF HEALTH C ARE PRACTITIONERS ’
602-CONTRACT AND RENDERE D BY THE HEALTH CARE PRACTITIONER OR SET OF
603-HEALTH CARE PRACTITI ONERS; AND
578+15–2101. 8
604579
605- (3) PAID PERIODICALLY RE GARDLESS OF UTILIZAT ION OF THE
606-SERVICES BY THE MEMB ERS OR PARTICIPANTS .
580+ (A) IN THIS SUBTITLE THE FOLLOWING WORDS HAVE THE MEANINGS 9
581+INDICATED. 10
607582
608- (B) SUBJECT TO THE REQUIR EMENTS OF SUBSECTION (C) OF THIS SECTION,
609-A HEALTH CARE PRACTI TIONER OR SET OF HEA LTH CARE PRACTITIONE RS IS NOT Ch. 297 2022 LAWS OF MARYLAND
583+ (B) “ADMINISTRATOR ” MEANS A CARRIER ADMINI STERING A SELF–FUNDED 11
584+GROUP HEALTH PLAN . 12
610585
611-– 14 –
612-ENGAGED IN INSURANCE BUSINESS AS DESCRIBED IN § 4–205 OF THIS ARTICLE
613-SOLELY BECAUSE THE H EALTH CARE PRACTITIO NER OR SET OF HEALTH CARE
614-PRACTITIONERS ENTERS INTO A CONTRACT WITH A CARRIER THAT INCLU DES
615-CAPITATED PAYMENTS F OR SERVICES PROVIDED BY THE HEALTH CARE
616-PRACTITIONER OR SET OF HEALTH CARE P RACTITIONERS .
586+ (C) “CARRIER” HAS THE MEANING STAT ED IN § 15–113 OF THIS TITLE. 13
617587
618- (C) A HEALTH CARE PRACTITI ONER OR SET OF HEALT H CARE
619-PRACTITIONERS IS NOT ENGAGED IN INSURANCE BUSINESS AS DESCRIBE D IN §
620-4–205(C) OF THIS ARTICLE SOLE LY BECAUSE THE HEALT H CARE PRACTITIONER OR
621-SET OF HEALTH CARE P RACTITIONERS ENTERS INTO A CONTRACT WITH AN
622-ADMINISTRATOR THAT I NCLUDES CAPITATED PA YMENTS FOR SERVICES PROVIDED
623-BY THE HEALTH CARE P RACTITIONER OR SET O F HEALTH CARE PRACTI TIONERS TO
624-MEMBERS OF A SELF –FUNDED GROUP HEALTH PLAN IF:
588+ (D) “HEALTH BENEFIT PLAN ” HAS THE MEANING STAT ED IN § 2–112.2 OF 14
589+THIS ARTICLE. 15
625590
626- (1) THE HEALTH CARE PRAC TITIONER OR SET OF HEAL TH CARE
627-PRACTITIONERS PARTIC IPATES IN THE ADMINI STRATOR’S NETWORK AND ACCEPT S
628-CAPITATED PAYMENTS ;
591+ (D) (E) “HEALTH CARE PRACTITIO NER” HAS THE MEANING STAT ED IN § 16
592+15–113 OF THIS TITLE. 17
629593
630- (2) THE SELF –FUNDED GROUP HEALTH PLAN RETAINS THE
631-OBLIGATION TO PROVID E ACCESS TO COVERED HEALTH CARE BENEFITS TO
632-PARTICIPANTS; AND
594+ (E) (F) “MEMBER” HAS THE MEANING STAT ED IN § 15–10A–01 OF THIS 18
595+TITLE. 19
633596
634- (3) THE CONTRACT DOES NO T INCLUDE OTHER REIM BURSEMENT
635-ARRANGEMENTS THAT AR E CONSIDERED ACTS OF AN INSURANCE BUSINES S UNDER
636-§ 4–205(C) OF THIS ARTICLE.
597+ (F) (G) “NETWORK” HAS THE MEANING STAT ED IN § 15–112 OF THIS 20
598+TITLE. 21
637599
638- (D) NOTWITHSTANDING SUBSE CTIONS (B) AND (C) OF THIS SECTION ,
639-NOTHING IN THIS SECT ION MAY BE CONSTRUED TO:
600+ (G) (H) “SET OF HEALTH CARE PRACTITIONERS ” HAS THE MEANING 22
601+STATED IN § 15–113 OF THIS TITLE. 23
640602
641- (1) ALTER ANY REQUIREMEN T FOR A CARRIER OR S ELF–FUNDED
642-GROUP HEALTH PLAN TO PAY A HOSPITAL OR RE LATED INSTITUTION TH E RATE
643-APPROVED BY THE HEALTH SERVICES COST REVIEW COMMISSION FOR HOSPIT AL
644-SERVICES; OR
603+ (H) (I) “PARTICIPANT” MEANS AN EMPLOYEE OR AN EMPLOYEE ’S 24
604+DEPENDENT WHO PARTIC IPATES IN A SELF–FUNDED GROUP HEALTH INSURANCE 25
605+PLAN. 26
645606
646- (2) SUPERSEDE THE HEALTH SERVICES COST REVIEW
647-COMMISSION’S JURISDICTION OR AU THORITY OVER RATE RE VIEW AND APPROVAL
648-FOR HOSPITAL SERVICE S.
607+15–2102. 27
649608
650- SECTION 2. AND BE IT FURTHER ENACTED, That, on or before December 31,
651-2023, and annually thereafter until December 31, 2032, the Maryland Health Care
652-Commission shall aggregate the following information and report it to the Senate Finance
653-Committee and the House Health and Government Operations Committee, in accordance
654-with § 2–1257 of the State Government Article:
655- LAWRENCE J. HOGAN, JR., Governor Ch. 297
609+ (A) THIS SECTION APPLIES TO ARRANGEMENTS UNDE R AN INSURED A 28
610+HEALTH BENEFIT PLAN OFFERED BY A CARRIER OR A SELF–FUNDED GROUP HEALTH 29
611+INSURANCE PLAN IN WH ICH A CAPITATED PAYM ENT IS: 30 14 HOUSE BILL 1148
656612
657-– 15 –
658- (1) the number and type of value–based arrangements entered into in
659-accordance with the authority established under Section 1 of this Act;
660613
661- (2) quality outcomes of the value–based arrangements;
662614
663- (3) the number of complaints made regarding value–based arrangements;
664-and
615+ (1) CALCULATED AS A FIXE D AMOUNT PER MEMBER OR PARTICIPANT 1
616+ASSIGNED OR ATTRIBU TED TO THE HEALTH CA RE PRACTITIONER OR S ET OF HEALTH 2
617+CARE PRACTITIONERS ; 3
665618
666- (4) the cost–effectiveness of the value–based arrangements; and
619+ (2) TO COVER THE PROVISI ON OF A SET OF SERVI CES DEFINED IN THE 4
620+HEALTH CARE PRACTITI ONER’S OR SET OF HEALTH C ARE PRACTITIONERS ’ 5
621+CONTRACT AND RENDERE D BY THE HEALTH CARE PRACTITIONER OR SET OF 6
622+HEALTH CARE PRACTITI ONERS; AND 7
667623
668- (5) the impact of two–sided incentive arrangements on the fee schedules of
669-health care practitioners included in the target budget that are not eligible providers.
624+ (3) PAID PERIODICALLY RE GARDLESS OF UTILIZAT ION OF THE 8
625+SERVICES BY THE MEMB ERS OR PARTICIPANTS . 9
670626
671- SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect
672-October 1, 2022.
627+ (B) SUBJECT TO THE REQUIR EMENTS OF SUBSECTION (C) OF THIS SECTION, 10
628+A HEALTH CARE PRACTI TIONER OR SET OF HEA LTH CARE PRACTITIONERS IS NOT 11
629+ENGAGED IN INSURANCE BUSINESS AS DESCRIBE D IN § 4–205 OF THIS ARTICLE 12
630+SOLELY BECAUSE THE H EALTH CARE PRACTITIO NER OR SET OF HEALTH CARE 13
631+PRACTITIONERS ENTERS INTO A CONTRACT WITH A CARRIER THAT INCLU DES 14
632+CAPITATED PAYMENTS F OR SERVICE S PROVIDED BY THE HE ALTH CARE 15
633+PRACTITIONER OR SET OF HEALTH CARE PRACT ITIONERS. 16
673634
674-Approved by the Governor, May 12, 2022.
635+ (C) A HEALTH CARE PRACTITI ONER OR SET OF HEALT H CARE 17
636+PRACTITIONERS IS NOT ENGAGED IN INSURANCE BUSINESS AS DESCRIBE D IN § 18
637+4–205(C) OF THIS ARTICLE SOLE LY BECAUSE THE HEALT H CARE PRACTITIONER OR 19
638+SET OF HEALTH CARE P RACTITIONERS ENTERS INTO A CONTRACT WITH AN 20
639+ADMINISTRATOR THAT I NCLUDES CAPITATED PA YMENTS FOR SERVICES PROVIDED 21
640+BY THE HEALTH CARE P RACTITIONER OR SET O F HEALTH CARE PRACTI TIONERS TO 22
641+MEMBERS OF A SELF –FUNDED GROUP HEALTH PLAN IF : 23
642+
643+ (1) THE HEALTH CARE PRAC TITIONER OR SET OF H EALTH CARE 24
644+PRACTITIONERS PARTIC IPATES IN THE ADMINI STRATOR’S NETWORK AND ACCEPT S 25
645+CAPITATED PAYMENTS ; 26
646+
647+ (2) THE SELF –FUNDED GROUP HEALTH PLAN RETAINS THE 27
648+OBLIGATION TO PROVID E ACCESS TO COVERED HEALTH CARE BENEFITS TO 28
649+PARTICIPANTS; AND 29
650+
651+ (3) THE CONTRACT DOES NO T INCLUDE OTHER REIM BURSEMENT 30
652+ARRANGEMENTS THAT AR E CONSIDERED ACTS OF AN INSURANCE BUSINES S UNDER 31
653+§ 4–205(C) OF THIS ARTICLE. 32
654+
655+ (D) NOTWITHSTANDING SUBSE CTIONS (B) AND (C) OF THIS SECTI ON, 33
656+NOTHING IN THIS SECT ION MAY BE CONSTRUED TO: 34
657+ HOUSE BILL 1148 15
658+
659+
660+ (1) ALTER ANY REQUIREMEN T FOR A CARRIER OR S ELF–FUNDED 1
661+GROUP HEALTH PLAN TO PAY A HOSPITAL OR RE LATED INSTITUTION TH E RATE 2
662+APPROVED BY THE HEALTH SERVICES COST REVIEW COMMISSION FOR HOSPIT AL 3
663+SERVICES; OR 4
664+
665+ (2) SUPERSEDE THE HEALTH SERVICES COST REVIEW 5
666+COMMISSION’S JURISDICTION OR AU THORITY OVER RATE RE VIEW AND APPROVAL 6
667+FOR HOSPITAL SERVICE S. 7
668+
669+ SECTION 2. AND BE IT FURTHER ENACTED, That, on or before December 31, 8
670+2023, and annually thereafter until December 31, 2032, the Maryland Health Care 9
671+Commission shall aggregate the following information and report it to the Senate Finance 10
672+Committee and the House Health and Government Operations Committee, in accordance 11
673+with § 2–1257 of the State Government Article: 12
674+
675+ (1) the number and type of value–based arrangements entered into in 13
676+accordance with the authority established under Section 1 of this Act; 14
677+
678+ (2) quality outcomes of the value–based arrangements; 15
679+
680+ (3) the number of complaints made regarding value–based arrangements; 16
681+and 17
682+
683+ (4) the cost–effectiveness of the value–based arrangements; and 18
684+
685+ (5) the impact of two–sided incentive arrangements on the fee schedules of 19
686+health care practitioners included in the target budget that are not eligible providers. 20
687+
688+ SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 21
689+October 1, 2022. 22
690+
691+
692+
693+
694+
695+Approved:
696+________________________________________________________________________________
697+ Governor.
698+________________________________________________________________________________
699+ Speaker of the House of Delegates.
700+________________________________________________________________________________
701+ President of the Senate.