MD
Maryland Senate Bill SB834

Maryland 2022 Regular Session

Maryland Senate Bill SB834 Compare Versions

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1- LAWRENCE J. HOGAN, JR., Governor Ch. 298
21
3-– 1 –
4-Chapter 298
5-(Senate Bill 834)
62
7-AN ACT concerning
3+EXPLANATION: CAPITALS INDICATE MATTER ADDE D TO EXISTING 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+ *sb0834*
89
9-Health Insurance – Two–Sided Incentive Arrangements and Capitated
10-Payments – Authorization
10+SENATE BILL 834
11+J5 2lr2361
12+ CF HB 1148
13+By: Senators Beidle and Kelley
14+Introduced and read first time: February 7, 2022
15+Assigned to: Finance
16+Committee Report: Favorable with amendments
17+Senate action: Adopted
18+Read second time: March 3, 2022
1119
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.
20+CHAPTER ______
2621
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)
22+AN ACT concerning 1
3223
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)
24+Health Insurance – Two–Sided Incentive Arrangements and Capitated 2
25+Payments – Authorization 3
3826
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)
27+FOR the purpose of providing that value–based arrangements established under certain 4
28+provisions of federal law are exempt from certain provisions of State law regulating 5
29+health care practitioner referrals; providing that a health care practitioner or set of 6
30+health care practitioners that accepts capitated payments in a certain manner but 7
31+does not perform certain other acts is not considered to be performing acts of an 8
32+insurance business; authorizing certain bonus or incentive–based compensation to 9
33+include a two–sided incentive arrangement through which a carrier may recoup 10
34+funds paid to an eligible provider in accordance with a written contract that includes 11
35+certain requirements; prohibiting a carrier from requiring participation in a carrier’s 12
36+bonus or incentive–based compensation or two–sided incentive arrangement 13
37+program or reducing a fee schedule based on nonparticipation; prohibiting 14
38+participation in a two–sided incentive arrangement from being the sole opportunity 15
39+for increases in reimbursement; and generally relating to health insurance, 16
40+two–sided incentive arrangements, and capitated payments. 17
4441
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. 298 2022 LAWS OF MARYLAND
42+BY repealing and reenacting, with amendments, 18
43+ Article – Health Occupations 19
44+Section 1–302(d)(12) 20
45+ Annotated Code of Maryland 21
46+ (2021 Replacement Volume) 22
5047
51-– 2 –
52- (2017 Replacement Volume and 2021 Supplement)
48+BY repealing and reenacting, with amendments, 23 2 SENATE BILL 834
5349
54-Preamble
5550
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
51+ Article – Insurance 1
52+Section 4–205(a), 15–113, and 15–1008(b) 2
53+ Annotated Code of Maryland 3
54+ (2017 Replacement Volume and 2021 Supplement) 4
5955
60-WHEREAS, Value–based arrangements may help to reduce disparities, expand
61-access to care, and improve outcomes, quality, and affordability; and
56+BY repealing and reenacting, without amendments, 5
57+ Article – Insurance 6
58+Section 4–205(b) and (c) and 15–1008(c) 7
59+ Annotated Code of Maryland 8
60+ (2017 Replacement Volume and 2021 Supplement) 9
6261
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
62+BY adding to 10
63+ Article – Insurance 11
64+Section 15–2101 and 15–2102 to be under the new subtitle “Subtitle 21. Capitated 12
65+Payments” 13
66+ Annotated Code of Maryland 14
67+ (2017 Replacement Volume and 2021 Supplement) 15
6868
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
69+Preamble 16
7270
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
71+WHEREAS, Value–based care is a health care practitioner payment structure that 17
72+ties practitioner revenue to improved health outcomes and the value of services delivered 18
73+rather than the volume of services provided; and 19
7974
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
75+WHEREAS, Value–based arrangements may help to reduce disparities, expand 20
76+access to care, and improve outcomes, quality, and affordability; and 21
8377
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,
78+WHEREAS, Value–based care models promote the Triple Aim framework used by 22
79+the Centers for Medicare and Medicaid Services to optimize health care systems through 23
80+better care and experience for individuals, better health for populations, and lower per 24
81+capita costs with demonstrated improvements in quality, cost–savings, and better 25
82+management of chronic illnesses; and 26
8983
90- SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND,
91-That the Laws of Maryland read as follows:
84+WHEREAS, Value–based care models continue to show promising results and 27
85+expand throughout the rest of the country and in Medicare and Medicaid, with broad 28
86+support from both public and private stakeholders; and 29
9287
93-Article – Health Occupations
88+ WHEREAS, Hospitals, health care practitioners, and payers should be allowed to 30
89+voluntarily participate in patient–focused, outcome–driven, value–based reimbursement 31
90+arrangements in Maryland’s commercial insurance markets that seek to align with 32
91+value–based programs under Maryland’s Total Cost of Care model and ensure that 33
92+practitioners have adequate contract protections and that consumers continue to have 34
93+access to high–quality care that promotes better health outcomes; and 35
9494
95-1–302.
95+ WHEREAS, Maryland has unique statutory barriers precluding commercial payers 36
96+from entering into certain value–based care arrangements outside of Maryland’s Total Cost 37
97+of Care model compared to other states in the nation; and 38 SENATE BILL 834 3
9698
97- (d) The provisions of this section do not apply to: LAWRENCE J. HOGAN, JR., Governor Ch. 298
9899
99-– 3 –
100100
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:
101+ WHEREAS, In Maryland, changes are needed to the health care practitioner bonus 1
102+and other compensation provisions applicable to the commercial market to allow 2
103+practitioners to enter into both two–sided incentive and capitation arrangements with 3
104+commercial plans as they do in other states and the Medicare and Medicaid segments; now, 4
105+therefore, 5
104106
105- (i) A Medicare shared savings program accountable care
106-organization authorized under 42 U.S.C. § 1395jjj;
107+ SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 6
108+That the Laws of Maryland read as follows: 7
107109
108- (ii) As authorized under 42 U.S.C. § 1315a:
110+Article – Health Occupations 8
109111
110- 1. An advance payment accountable care organization
111-model;
112+1–302. 9
112113
113- 2. A pioneer accountable care organization model; or
114+ (d) The provisions of this section do not apply to: 10
114115
115- 3. A next generation accountable care organization model;
116+ (12) Subject to subsection (f) of this section, a health care practitioner who 11
117+has a compensation arrangement with a health care entity, if the compensation 12
118+arrangement is funded by or paid under: 13
116119
117- (iii) An alternative payment model approved by the federal Centers
118-for Medicare and Medicaid Services; [or]
120+ (i) A Medicare shared savings program accountable care 14
121+organization authorized under 42 U.S.C. § 1395jjj; 15
119122
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
123+ (ii) As authorized under 42 U.S.C. § 1315a: 16
123124
124- (V) A VALUE–BASED ARRANGEMENT TH AT MEETS THE
125-REQUIREMENTS OF 42 C.F.R. § 411.357(AA)(1) THROUGH (3).
125+ 1. An advance payment accountable care organization 17
126+model; 18
126127
127-Article – Insurance
128+ 2. A pioneer accountable care organization model; or 19
128129
129-4–205.
130+ 3. A next generation accountable care organization model; 20
130131
131- (a) This section does not apply to:
132+ (iii) An alternative payment model approved by the federal Centers 21
133+for Medicare and Medicaid Services; [or] 22
132134
133- (1) the lawful transaction of surplus lines insurance;
135+ (iv) Another model approved by the federal Centers for Medicare and 23
136+Medicaid Services that may be applied to health care services provided to both Medicare 24
137+beneficiaries and individuals who are not Medicare beneficiaries; OR 25
134138
135- (2) the lawful transaction of reinsurance by insurers;
139+ (V) A VALUE–BASED ARRANGEMENT TH AT MEETS THE 26
140+REQUIREMENTS OF 42 C.F.R. § 411.357(AA)(1) THROUGH (3). 27
136141
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;
142+Article – Insurance 28
141143
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. 298 2022 LAWS OF MARYLAND
144+4–205. 29
146145
147-– 4 –
146+ (a) This section does not apply to: 30 4 SENATE BILL 834
148147
149- (5) an attorney while acting in the ordinary relation of attorney and client
150-in the adjustment of claims or losses; [or]
151148
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
156149
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.
150+ (1) the lawful transaction of surplus lines insurance; 1
161151
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.
152+ (2) the lawful transaction of reinsurance by insurers; 2
165153
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:
154+ (3) transactions in the State that involve, and are subsequent to the 3
155+issuance of, a policy that was lawfully solicited, written, and delivered outside of the State 4
156+covering only a subject of insurance not resident, located, or expressly to be performed in 5
157+the State at the time of issuance of the policy; 6
168158
169- (1) making or proposing to make, as an insurer, an insurance contract;
159+ (4) transactions that involve insurance contracts that are independently 7
160+procured through negotiations occurring entirely outside of the State and that are reported 8
161+and on which the premium tax is paid in accordance with §§ 4–210 and 4–211 of this 9
162+subtitle; 10
170163
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;
164+ (5) an attorney while acting in the ordinary relation of attorney and client 11
165+in the adjustment of claims or losses; [or] 12
174166
175- (3) taking or receiving an application for insurance;
167+ (6) unless otherwise determined by the Commissioner, transactions in the 13
168+State that involve group or blanket insurance or group annuities if the master policy of the 14
169+group was lawfully issued and delivered in another state in which the person was 15
170+authorized to engage in insurance business; OR 16
176171
177- (4) receiving or collecting premiums, commissions, membership fees,
178-assessments, dues, or other consideration for insurance;
172+ (7) A HEALTH CARE PRACTI TIONER OR SET OF HEA LTH CARE 17
173+PRACTITIONERS , AS DEFINED IN § 15–113 OF THIS ARTICLE , THAT ACCEPTS 18
174+CAPITATED PAYMENTS I N ACCORDANCE WITH § 15–2102 OF THIS ARTICLE , BUT 19
175+PERFORMS NO OTHER AC TS CONSIDERED ACTS O F AN INSURANCE BUSIN ESS. 20
179176
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;
177+ (b) An insurer or other person may not, directly or indirectly, do any of the acts 21
178+of an insurance business set forth in subsection (c) of this section, except as provided by 22
179+and in accordance with the specific authorization of statute. 23
182180
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:
181+ (c) Any of the following acts in the State, effected by mail or otherwise, is 24
182+considered to be doing an insurance business in the State: 25
187183
188- (i) solicit, negotiate, procure, or effect insurance or the renewal of
189-insurance;
184+ (1) making or proposing to make, as an insurer, an insurance contract; 26
190185
191- (ii) disseminate information about coverage or rates;
186+ (2) making or proposing to make, as guarantor or surety insurer, a contract 27
187+of guaranty or suretyship as a vocation and not merely incidental to another legitimate 28
188+business or activity of the guarantor or surety insurer; 29
192189
193- (iii) forward an application; LAWRENCE J. HOGAN, JR., Governor Ch. 298
190+ (3) taking or receiving an application for insurance; 30
194191
195-– 5 –
192+ (4) receiving or collecting premiums, commissions, membership fees, 31
193+assessments, dues, or other consideration for insurance; 32
194+ SENATE BILL 834 5
196195
197- (iv) deliver a policy or insurance contract;
198196
199- (v) inspect risks;
197+ (5) issuing or delivering an insurance contract to a resident of the State or 1
198+a person authorized to do business in the State; 2
200199
201- (vi) fix rates;
200+ (6) except as provided in subsection (d) of this section, with respect to a 3
201+subject of insurance resident, located, or to be performed in the State, directly or indirectly 4
202+acting as an insurance producer for, or otherwise representing or helping on behalf of 5
203+another, an insurer or other person to: 6
202204
203- (vii) investigate or adjust claims or losses;
205+ (i) solicit, negotiate, procure, or effect insurance or the renewal of 7
206+insurance; 8
204207
205- (viii) transact matters arising out of an insurance contract after the
206-insurance contract becomes effective; or
208+ (ii) disseminate information about coverage or rates; 9
207209
208- (ix) in any other manner represent or help an insurer or other person
209-to transact insurance business;
210+ (iii) forward an application; 10
210211
211- (7) doing any kind of insurance business specifically recognized as doing
212-an insurance business under statutes relating to insurance;
212+ (iv) deliver a policy or insurance contract; 11
213213
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
214+ (v) inspect risks; 12
217215
218- (9) as an insurer transacting any other business in the State.
216+ (vi) fix rates; 13
219217
220-15–113.
218+ (vii) investigate or adjust claims or losses; 14
221219
222- (a) (1) In this section the following words have the meanings indicated.
220+ (viii) transact matters arising out of an insurance contract after the 15
221+insurance contract becomes effective; or 16
223222
224- (2) “Carrier” means:
223+ (ix) in any other manner represent or help an insurer or other person 17
224+to transact insurance business; 18
225225
226- (i) an insurer;
226+ (7) doing any kind of insurance business specifically recognized as doing 19
227+an insurance business under statutes relating to insurance; 20
227228
228- (ii) a nonprofit health service plan;
229+ (8) doing or proposing to do any insurance business that is substantially 21
230+equivalent to any act listed in this subsection in a manner designed to evade the statutes 22
231+relating to insurance; or 23
229232
230- (iii) a health maintenance organization;
233+ (9) as an insurer transacting any other business in the State. 24
231234
232- (iv) a dental plan organization; or
235+15–113. 25
233236
234- (v) any other person that provides health benefit plans subject to
235-regulation by the State.
237+ (a) (1) In this section the following words have the meanings indicated. 26
236238
237- (3) “ELIGIBLE PROVIDER ” MEANS:
239+ (2) “Carrier” means: 27
238240
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. 298 2022 LAWS OF MARYLAND
241+ (i) an insurer; 28
242242
243-– 6 –
243+ (ii) a nonprofit health service plan; 29 6 SENATE BILL 834
244244
245- (II) A SET OF HEALTH CARE PRACTITIONERS THAT
246-VOLUNTARILY PARTICIP ATE IN A TWO–SIDED INCENTIVE ARRA NGEMENT.
247245
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.
251246
252- (5) “SET OF HEALTH CARE PR ACTITIONERS” MEANS:
247+ (iii) a health maintenance organization; 1
253248
254- (I) A GROUP PRACTICE ;
249+ (iv) a dental plan organization; or 2
255250
256- (II) A CLINICALLY INTEGRA TED ORGANIZATION EST ABLISHED
257-IN ACCORDANCE WITH SUBTITLE 19 OF THIS TITLE;
251+ (v) any other person that provides health benefit plans subject to 3
252+regulation by the State. 4
258253
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
254+ (3) “ELIGIBLE PROVIDER ” MEANS: 5
262255
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.
256+ (I) A LICENSED PHYSICIAN , AS DEFINED IN § 14–101 OF THE 6
257+HEALTH OCCUPATIONS ARTICLE, WHO VOLUNTARILY PARTIC IPATES IN A 7
258+TWO–SIDED INCENTIVE ARRA NGEMENT; OR 8
267259
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.
260+ (II) A SET OF HEALTH CARE PRACTITIONERS THAT 9
261+VOLUNTARILY PARTICIP ATE IN A TWO–SIDED INCENTIVE ARRA NGEMENT. 10
274262
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.
263+ [(3)] (4) “Health care practitioner” means an individual who is licensed, 11
264+certified, or otherwise authorized under the Health Occupations Article to provide health 12
265+care services. 13
278266
279- (c) (1) [In this subsection, “set of health care practitioners” means:
267+ (5) “SET OF HEALTH CARE PR ACTITIONERS” MEANS: 14
280268
281- (i) a group practice;
269+ (I) A GROUP PRACTICE ; 15
282270
283- (ii) a clinically integrated organization established in accordance
284-with Subtitle 19 of this title; or
271+ (II) A CLINICALLY INTEGRA TED ORGANIZATION EST ABLISHED 16
272+IN ACCORDANCE WIT H SUBTITLE 19 OF THIS TITLE; 17
285273
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. 298
274+ (III) AN ACCOUNTABLE CARE ORGANIZATION ESTABLI SHED IN 18
275+ACCORDANCE WITH 42 U.S.C. § 1395JJJ AND ANY APPLICAB LE FEDERAL 19
276+REGULATIONS ; OR 20
288277
289-– 7 –
278+ (IV) A CLINICALLY INTEGRA TED NETWORK THAT IS A PROVIDER 21
279+ENTITY THAT MEETS TH E CRITERIA ESTABLISHED IN GUIDA NCE ISSUED BY THE 22
280+FEDERAL TRADE COMMISSION, INCLUDING A NETWORK OF BEHAVIORAL HEALTH 23
281+CARE PROGRAMS LICENS ED UNDER § 7.5–401 OF THE HEALTH – GENERAL ARTICLE. 24
290282
291- (2)] This section does not prohibit a carrier from:
283+ (6) “TWO–SIDED INCENTIVE ARRA NGEMENT” MEANS AN 25
284+ARRANGEMENT BETWEEN AN ELIGIBLE PROVIDER AN D A CARRIER IN WHICH THE 26
285+ELIGIBLE PROVIDER MA Y EARN AN INCENTIVE AND A CARRIER MAY RE COUP FUNDS 27
286+FROM THE ELIGIBLE PR OVIDER IN ACCORDANCE WITH THE TERMS OF A CONTRACT 28
287+ENTERED INTO WITH TH E ELIGIBLE PROVIDER THAT MEETS THE REQUI REMENTS OF 29
288+THIS SECTION. 30
289+ SENATE BILL 834 7
292290
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
296291
297- (II) ENTERING INTO A TWO –SIDED INCENTIVE ARRA NGEMENT
298-WITH AN ELIGIBLE PRO VIDER.
292+ (b) A carrier may not reimburse a health care practitioner in an amount less than 1
293+the sum or rate negotiated in the carrier’s provider contract with the health care 2
294+practitioner. 3
299295
300- (2) A BONUS OR OTHER INCEN TIVE–BASED COMPENSATION
301-PROGRAM OR TWO –SIDED INCENTIVE ARRA NGEMENT AUTHORIZED U NDER THIS
302-SECTION:
296+ (c) (1) [In this subsection, “set of health care practitioners” means: 4
303297
304- (i) [does] MAY not create a disincentive to the provision of medically
305-appropriate or medically necessary health care services; and
298+ (i) a group practice; 5
306299
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.
300+ (ii) a clinically integrated organization established in accordance 6
301+with Subtitle 19 of this title; or 7
309302
310- (3) A bonus or other incentive–based compensation OR TWO–SIDED
311-INCENTIVE ARRANGEMEN T AUTHORIZED under this [subsection] SECTION:
303+ (iii) an accountable care organization established in accordance with 8
304+42 U.S.C. § 1395jjj and any applicable federal regulations. 9
312305
313- (i) if applicable, shall promote HEALTH EQUITY , IMPROVEMENT
314-OF HEALTH CARE OUTCO MES, AND the provision of preventive health care services; or
306+ (2)] This section does not prohibit a carrier from: 10
315307
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 :
308+ (I) providing bonuses or other incentive–based compensation to a 11
309+health care practitioner or a set of health care practitioners [if the bonus or other 12
310+incentive–based compensation:]; OR 13
320311
321- 1. the performance measures, INCLUDING THE SOURCE OF
322-THE MEASURES ;
312+ (II) ENTERING INTO A TWO –SIDED INCENTIVE ARRA NGEMENT 14
313+WITH AN ELIGIBLE PRO VIDER. 15
323314
324- 2. the method AND THE TIME PERIOD for calculating
325-whether the performance measures have been satisfied; [and]
315+ (2) A BONUS OR OTHER INCEN TIVE–BASED COMPENSATION 16
316+PROGRAM OR TWO –SIDED INCENTIVE ARRA NGEMENT AUTHORIZED U NDER THIS 17
317+SECTION: 18
326318
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
319+ (i) [does] MAY not create a disincentive to the provision of medically 19
320+appropriate or medically necessary health care services; and 20
330321
331- 4. IF APPLICABLE , THE RISK–ADJUSTMENT METHOD
332-USED.
333- Ch. 298 2022 LAWS OF MARYLAND
322+ (ii) if the carrier is a health maintenance organization, [complies] 21
323+SHALL COMPLY with the provisions of § 19–705.1 of the Health – General Article. 22
334324
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.
325+ (3) A bonus or other incentive–based compensation OR TWO–SIDED 23
326+INCENTIVE ARRANGEMEN T AUTHORIZED under this [subsection] SECTION: 24
338327
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.
328+ (i) if applicable, shall promote HEALTH EQUITY , IMPROVEMENT 25
329+OF HEALTH CARE OUTCO MES, AND the provision of preventive health care services; or 26
345330
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 .
331+ (ii) may reward a health care practitioner [or], a set of health care 27
332+practitioners, OR AN ELIGIBLE PROVI DER, based on satisfaction of performance 28
333+measures, if the following is agreed on in writing by the carrier and the health care 29
334+practitioner [or], set of health care practitioners, OR ELIGIBLE PROVIDER : 30
335+ 8 SENATE BILL 834
350336
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:
354337
355- (I) A HEALTH CARE PRACTITIO NER OR SET OF HEALTH CARE
356-PRACTITIONERS TO PAR TICIPATE IN THE CARR IER’S BONUS OR OTHER
357-INCENTIVE–BASED COMPENSATION P ROGRAM; OR
338+ 1. the performance measures, INCLUDING THE SOURCE OF 1
339+THE MEASURES ; 2
358340
359- (II) AN ELIGIBLE PROVIDER TO PARTICIPATE IN TH E CARRIER’S
360-TWO–SIDED INCENTIVE ARRA NGEMENT PROGRAM .
341+ 2. the method AND THE TIME PERIOD for calculating 3
342+whether the performance measures have been satisfied; [and] 4
361343
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.
344+ 3. the method by which the health care practitioner [or], set 5
345+of health care practitioners, OR ELIGIBLE PROVIDER may request reconsideration of the 6
346+calculations by the carrier; AND 7
366347
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:
348+ 4. IF APPLICABLE , THE RISK–ADJUSTMENT METHOD 8
349+USED. 9
369350
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;
351+ (4) Acceptance of a bonus or other incentive–based compensation OR 10
352+TWO–SIDED INCENTIVE ARRA NGEMENT under this subsection shall be voluntary. 11
373353
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]
354+ (5) A CARRIER MAY NOT REDU CE THE FEE SCHEDULE OF A HEALTH 12
355+CARE PRACTITIONER , OR A SET OF HEALTH CARE PRACTITIONERS , OR AN ELIGIBLE 13
356+PROVIDER SOLELY BECAUSE THE HEALTH C ARE PRACTITIONER , OR SET OF HEALTH 14
357+CARE PRACTITIONERS , OR ELIGIBLE PROVIDER DOES NOT PARTICIPATE IN THE 15
358+CARRIER’S BONUS OR OTHER INC ENTIVE–BASED COMPENSATION O R TWO–SIDED 16
359+INCENTIVE ARRANGEMEN T PROGRAM. 17
376360
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. 298
361+ (6) PARTICIPATION IN A TW O–SIDED INCENTIVE ARRA NGEMENT MAY 18
362+NOT BE THE SOLE OPPO RTUNITY FOR A HEALTH CARE PRACTITIONER OR A SET OF 19
363+HEALTH CARE PRACTITI ONERS TO BE ELIGIBLE TO RECEIVE INCREASES IN 20
364+REIMBURSEMENT . 21
380365
381-– 9 –
382- 1. increase or reduce the practitioner’s level of
383-reimbursement; [and]
366+ [(5)] (6) (7) A carrier may not require [a health care practitioner or a set of 22
367+health care practitioners to participate in the carrier’s bonus or incentive–based 23
368+compensation program] as a condition of participation in the carrier’s provider network: 24
384369
385- 2. provide a bonus or other incentive–based compensation to
386-the practitioner; AND
370+ (I) A HEALTH CARE PRACTI TIONER OR SET OF HEA LTH CARE 25
371+PRACTITIONERS TO PAR TICIPATE IN THE CARR IER’S BONUS OR OTHER 26
372+INCENTIVE–BASED COMPENSATION P ROGRAM; OR 27
387373
388- 3. RECOUP COMPENSATION FROM AN ELIGIBLE
389-PROVIDER UNDER A TWO –SIDED INCENTIVE ARRA NGEMENT; AND
374+ (II) AN ELIGIBLE PROVIDER TO PARTICIPATE IN THE C ARRIER’S 28
375+TWO–SIDED INCENTIVE ARRA NGEMENT PROGRAM . 29
390376
391- (IV) A SUMMARY OF THE TER MS OF A TWO –SIDED INCENTIVE
392-ARRANGEMENT PROGRAM .
377+ [(6)] (7) (8) A health care practitioner, a set of health care practitioners, AN 30
378+ELIGIBLE PROVIDER , a health care practitioner’s designee, [or] a designee of a set of 31
379+health care practitioners, OR A DESIGNEE OF AN ELIGIBLE PROVIDER may file a 32
380+complaint with the Administration regarding a violation of this subsection. 33
381+ SENATE BILL 834 9
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:
397383
398- (i) in writing [at the time of] BEFORE A contract execution;
384+ (d) (1) A carrier shall provide a health care practitioner, A SET OF HEALTH 1
385+CARE PRACTITIONERS , OR AN ELIGIBLE PROVI DER with a copy of: 2
399386
400- (ii) in writing or electronically 30 days [prior to] BEFORE a change;
401-and
387+ (i) a schedule of ALL applicable fees [for up to] OR the [fifty] 50 3
388+most common services billed by a health care practitioner in that specialty, WHICHEVER 4
389+IS LESS; 5
402390
403- (iii) in writing or electronically [upon] ON request of the health care
404-practitioner, SET OF HEALTH CARE P RACTITIONERS , OR ELIGIBLE PROVIDER .
391+ (ii) a description of the coding guidelines used by the carrier that are 6
392+applicable to the services billed by a health care practitioner in that specialty; [and] 7
405393
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.
394+ (iii) the information about the practitioner and the methodology that 8
395+the carrier uses to determine whether to: 9
410396
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.
397+ 1. increase or reduce the practitioner’s level of 10
398+reimbursement; [and] 11
414399
415- (5) The Administration may adopt regulations to carry out the provisions
416-of this subsection.
400+ 2. provide a bonus or other incentive–based compensation to 12
401+the practitioner; AND 13
417402
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.
403+ 3. RECOUP COMPENSATION FROM AN ELIGIBLE 14
404+PROVIDER UNDER A TWO –SIDED INCENTIVE ARRA NGEMENT; AND 15
422405
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. 298 2022 LAWS OF MARYLAND
406+ (IV) A SUMMARY OF THE TER MS OF A TWO –SIDED INCENTIVE 16
407+ARRANGEMENT PROGRAM . 17
427408
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.
409+ (2) Except as provided in paragraph (4) of this subsection, a carrier shall 18
410+provide the information required under paragraph (1) of this subsection in the manner 19
411+indicated in each of the following instances: 20
433412
434- (3) ACCEPTANCE OF A CAPITATED PAYMENT SH ALL BE VOLUNTARY .
413+ (i) in writing [at the time of] BEFORE A contract execution; 21
435414
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 CARRIER AND THE ELIGIBLE PRO VIDER THAT AT A MINI MUM:
415+ (ii) in writing or electronically 30 days [prior to] BEFORE a change; 22
416+and 23
440417
441- (I) ESTABLISH A TARGET B UDGET FOR:
418+ (iii) in writing or electronically [upon] ON request of the health care 24
419+practitioner, SET OF HEALTH CARE P RACTITIONERS , OR ELIGIBLE PROVIDER . 25
442420
443- 1. THE TOTAL COST OF CA RE OF A POPULATION O F
444-PATIENTS ADJUSTED FO R RISK AND POPULATIO N SIZE; OR
421+ (3) Except as provided in paragraph (4) of this subsection, a carrier shall 26
422+make the pharmaceutical formulary that the carrier uses available to a health care 27
423+practitioner, A SET OF HEALTH CARE PRACTITIO NERS, OR AN ELIGIBLE PROVI DER 28
424+electronically. 29
445425
446- 2. THE COST OF AN EPISO DE OF CARE;
426+ (4) On written request of a health care practitioner, A SET OF HEALTH 30
427+CARE PRACTITIONERS , OR AN ELIGIBLE PROVI DER, a carrier shall provide the 31
428+information required under paragraphs (1) and (3) of this subsection in writing. 32 10 SENATE BILL 834
447429
448- (II) LIMIT RECOUPMENT TO NOT MORE THAN 50% OF THE
449-EXCESS ABOVE THE MUT UALLY AGREED ON TARGET ESTABLISHED IN ACCOR DANCE
450-WITH ITEM (I) OF THIS PARAGRAPH ;
451430
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 ;
455431
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;
432+ (5) The Administration may adopt regulations to carry out the provisions 1
433+of this subsection. 2
459434
460- (V) FOLLOWING GOOD FAITH NEGOTIATIONS , PROVIDE AN
461-OPPORTUNITY FOR AN A UDIT BY AN INDEPENDE NT THIRD PARTY AND A N
462-INDEPENDENT THIRD–PARTY DISPUTE RESOLU TION PROCESS;
435+ (e) (1) A carrier that compensates health care practitioners OR A SET OF 3
436+HEALTH CARE PRACTITI ONERS wholly or partly on a capitated basis IN ACCORDANCE 4
437+WITH § 15–2102 OF THIS ARTICLE may not retain any capitated fee attributable to an 5
438+enrollee or covered person during an enrollee’s or covered person’s contract year. 6
463439
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:
440+ (2) A carrier is in compliance with paragraph (1) of this subsection if, 7
441+within 45 days after an enrollee or covered person chooses or obtains health care from a 8
442+health care practitioner OR A SET OF HEALTH C ARE PRACTITIONERS , the carrier pays 9
443+to the health care practitioner OR SET OF HEALTH CAR E PRACTITIONERS all accrued but 10
444+unpaid capitated fees attributable to that enrollee or person that the health care 11
445+practitioner OR SET OF HEALTH CAR E PRACTITIONERS would have received had the 12
446+enrollee or person chosen the health care practitioner OR SET OF HEALTH CAR E 13
447+PRACTITIONERS at the beginning of the enrollee’s or covered person’s contract year. 14
466448
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. 298
449+ (3) ACCEPTANCE OF A CAPIT ATED PAYMENT SHALL B E VOLUNTARY . 15
471450
472-– 11 –
473- 2. MATERIAL CHANGES OCC UR IN HEALTH CARE
474-ECONOMICS, HEALTH CARE DELIVERY , OR REGULATIONS THAT IMPACT THE
475-ARRANGEMENT ; AND
451+ (F) (1) UNDER A TWO–SIDED INCENTIVE ARRA NGEMENT THAT COMPLIE S 16
452+WITH THE REQUIREMENT S OF THIS SECTION, A CARRIER MAY RECOUP FUNDS PAID 17
453+TO AN ELIGIBLE PROVI DER BASED ON THE TER MS OF A WRITTEN CONT RACT 18
454+BETWEEN THE CARRIER AND THE ELIGIBLE PRO VIDER THAT AT A MINI MUM: 19
476455
477- (VII) REQUIRE THE CARRIER TO PAY ANY INCENTIVE TO OR
478-REQUEST ANY RECOUPME NT FROM TH E 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.
456+ (I) ESTABLISH A TARGET B UDGET FOR: 20
482457
483- (2) UNLESS MUTUALLY AGREE D TO BY AN ELIGIBLE PROVIDER AND A
484-CARRIER, AN ARRANGEMENT ENTERED INTO UNDER THIS SUBS ECTION 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 .
458+ 1. THE TOTAL COST OF CA RE OF A POPULATION O F 21
459+PATIENTS ADJUSTED FO R RISK AND POPULATIO N SIZE; OR 22
488460
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:
461+ 2. THE COST OF AN EPISO DE OF CARE; 23
496462
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 T HE POPULATION
499-OR EPISODE OF CARE ; AND
463+ (II) LIMIT RECOUPMENT TO NOT MORE THAN 50% OF THE 24
464+EXCESS ABOVE THE MUT UALLY AGREED ON TARGET ESTABLISHED IN ACCOR DANCE 25
465+WITH ITEM (I) OF THIS PARAGRAPH ; 26
500466
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 .
467+ (III) SPECIFY A MUTUALLY A GREED ON MAXIMUM LIA BILITY FOR 27
468+TOTAL RECOUPMENT THA T MAY NOT EXCEED 10% OF THE ANNUAL PAYMEN TS FROM 28
469+THE CARRIER TO THE E LIGIBLE PROVIDER ; 29
504470
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 .
471+ (IV) PROVIDE AN OPPORTUNI TY FOR GAINS BY AN E LIGIBLE 30
472+PROVIDER THAT IS GRE ATER THAN THE OPPORT UNITY FOR RECOUPMENT BY THE 31
473+CARRIER; 32
474+ SENATE BILL 834 11
508475
509- (5) THE OPPORTUNITY FOR I NDEPENDENT THIRD –PARTY DISPUTE
510-RESOLUTION PROVIDED FOR IN PARAGRAPH (1)(V) OF THIS SUBSECTION M AY NOT
511-BE REQUIRED TO BE EX HAUSTED BEFORE A MEM BER OR MEMBER ’S
512-REPRESENTATIVE IS AL LOWED TO FILE A N APPEAL OF A COVERA GE DECISION
513-UNDER § 15–10D–02 OF THIS TITLE.
514476
515- (6) NOTHING IN THIS SUBSE CTION MAY BE CONSTRU ED TO:
516- Ch. 298 2022 LAWS OF MARYLAND
477+ (V) FOLLOWING GOOD FAITH NEGOTIATIONS , PROVIDE AN 1
478+OPPORTUNITY FOR AN A UDIT BY AN INDEPENDE NT THIRD PARTY AND A N 2
479+INDEPENDENT THIRD–PARTY DISPUTE RESOLU TION PROCESS; 3
517480
518-– 12 –
519- (I) ALTER ANY REQUIREMEN T FOR A CARRIER TO P AY A
520-HOSPITAL OR RELATED INSTITUTION THE RATE APPROVED BY THE HEALTH
521-SERVICES COST REVIEW COMMISSION FOR HOSPIT AL SERVICES; OR
481+ (VI) REQUIRE THE CARRIER AND THE ELIGIBLE PRO VIDER TO 4
482+NEGOTIATE IN GOOD FA ITH ADJUSTMENTS TO T HE TARGET BUDGET WHE N: 5
522483
523- (II) SUPERSEDE THE HEALTH SERVICES COST REVIEW
524-COMMISSION’S JURISDICTION OR AU THORITY OVER RATE RE VIEW AND APPROVAL
525-FOR HOSPITAL SERVICE S.
484+ 1. CERTAIN CIRCUMSTANCE S BEYOND THE CONTROL OF 6
485+THE CARRIER OR THE E LIGIBLE PROVIDER ARI SE, INCLUDING CHANGES IN 7
486+HOSPITAL RATES ; AND 8
526487
527-15–1008.
488+ 2. MATERIAL CHANGES OCC UR IN HEALTH CARE 9
489+ECONOMICS, HEALTH CARE DELIVERY , OR REGULATIONS THAT IMPACT THE 10
490+ARRANGEMENT ; AND 11
528491
529- (b) This section does not apply to an adjustment to reimbursement:
492+ (VII) REQUIRE THE CARRIER TO PAY ANY INCENTIVE TO OR 12
493+REQUEST ANY RECOUPME NT FROM TH E ELIGIBLE PROVIDER WITHIN 6 MONTHS 13
494+AFTER THE END OF THE CONTRACT YEAR , UNLESS THE CARRIER O R ELIGIBLE 14
495+PROVIDER INITIATES A DISPUTE RELATING TO THE RECOUPMENT OR IN CENTIVE 15
496+AMOUNT. 16
530497
531- (1) made as part of an annual contracted reconciliation of a risk sharing
532-arrangement under an administrative service provider contract; OR
498+ (2) UNLESS MUTUALLY AGREE D TO BY AN ELIGIBLE PROVIDER AND A 17
499+CARRIER, AN ARRANGEMENT ENTERED INTO UNDER THIS SUBS ECTION MAY NOT 18
500+PROVIDE AN OPPORTUNI TY FOR RECOUPMENT BY THE CARRIER BASED ON THE 19
501+ELIGIBLE PROVIDER ’S PERFORMANCE DURING THE FIRST 12 MONTHS OF THE 20
502+ARRANGEMENT . 21
533503
534- (2) MADE AS PART OF A TW O–SIDED INCENTIVE ARRA NGEMENT THAT
535-COMPLIES WITH § 15–113 OF THIS TITLE.
504+ (3) A CARRIER THAT ENTERS INTO A TWO –SIDED INCENTIVE 22
505+ARRANGEMENT WITH AN ELIGIBLE PROVIDER IN WHICH THE AMOUNT OF ANY 23
506+PAYMENT IS DETERMINE D, IN WHOLE OR IN PART , ON THE TOTAL COST OF CARE OF 24
507+A POPULATION OF PATI ENTS OR AN EPISODE O F CARE, SHALL, AT LEAST 25
508+QUARTERLY , DISCLOSE TO THE ELIG IBLE PROVIDER THE FO LLOWING INFORMATION 26
509+IN A MANNER THAT MEE TS FEDERAL AND STATE DATA USE AND PR IVACY 27
510+STANDARDS: 28
536511
537- (c) (1) If a carrier retroactively denies reimbursement to a health care
538-provider, the carrier:
512+ (I) ANY AMOUNT PAID TO A NOTHER HEALTH CARE P ROVIDER 29
513+THAT IS INCLUDED IN THE TOTAL COST OF CA RE OF A PATIENT IN T HE POPULATION 30
514+OR EPISODE OF CARE ; AND 31
539515
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
516+ (II) ANY COPAYMENT , COINSURANCE , OR DEDUCTIBLE THAT I S 32
517+INCLUDED IN THE TOTA L COST OF CARE OF A PATIENT IN THE POPUL ATION OR 33
518+EPISODE OF CARE . 34
519+ 12 SENATE BILL 834
544520
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.
548521
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.
522+ (4) UNLESS MUTUALLY AGREE D TO BY THE CARRIER AND ELIGIBLE 1
523+PROVIDER, A TWO–SIDED INCENTIVE ARRA NGEMENT MAY NOT BE A MENDED 2
524+DURING THE TERM OF T HE CONTRACT . 3
552525
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.
526+ (5) THE OPPORTUNITY FOR I NDEPENDENT THIRD –PARTY DISPUTE 4
527+RESOLUTION PROVIDED FOR IN PARAGRAPH (1)(V) OF THIS SUBSECTION M AY NOT 5
528+BE REQUIRED TO BE EX HAUSTED BEFORE A MEM BER OR MEMBER ’S 6
529+REPRESENTATIVE IS AL LOWED TO FILE A N APPEAL OF A COVERA GE DECISION 7
530+UNDER § 15–10D–02 OF THIS TITLE. 8
556531
557-SUBTITLE 21. CAPITATED PAYMENTS.
532+ (6) NOTHING IN THIS SUBSE CTION MAY BE CONSTRU ED TO: 9
558533
559-15–2101.
534+ (I) ALTER ANY REQUIREMEN T FOR A CARRIER TO P AY A 10
535+HOSPITAL OR RELATED INSTITUTION THE RATE APPROVED BY THE HEALTH 11
536+SERVICES COST REVIEW COMMISSION FOR HOSPIT AL SERVICES; OR 12
560537
561- (A) IN THIS SUBTITLE THE FOLLOWING WORDS HAVE THE MEANINGS
562-INDICATED.
563- LAWRENCE J. HOGAN, JR., Governor Ch. 298
538+ (II) SUPERSEDE THE HEALTH SERVICES COST REVIEW 13
539+COMMISSION’S JURISDICTION OR AU THORITY OVER RATE RE VIEW AND APPROVAL 14
540+FOR HOSPITAL SERVICE S. 15
564541
565-– 13 –
566- (B) “ADMINISTRATOR ” MEANS A CARRIER ADMI NISTERING A SELF–FUNDED
567-GROUP HEALTH PLAN .
542+15–1008. 16
568543
569- (C) “CARRIER” HAS THE MEANING STAT ED IN § 15–113 OF THIS TITLE.
544+ (b) This section does not apply to an adjustment to reimbursement: 17
570545
571- (D) “HEALTH BENEFIT PLAN ” HAS THE MEANING STAT ED IN § 2–112.2 OF
572-THIS ARTICLE.
546+ (1) made as part of an annual contracted reconciliation of a risk sharing 18
547+arrangement under an administrative service provider contract; OR 19
573548
574- (D) (E) “HEALTH CARE PRACTITIO NER” HAS THE MEANING STAT ED IN §
575-15–113 OF THIS TITLE.
549+ (2) MADE AS PART OF A TW O–SIDED INCENTIVE ARRA NGEMENT THAT 20
550+COMPLIES WITH § 15–113 OF THIS TITLE. 21
576551
577- (E) (F) “MEMBER” HAS THE MEANING STAT ED IN § 15–10A–01 OF THIS
578-TITLE.
552+ (c) (1) If a carrier retroactively denies reimbursement to a health care 22
553+provider, the carrier: 23
579554
580- (F) (G) “NETWORK” HAS THE MEANING STAT ED IN § 15–112 OF THIS
581-TITLE.
555+ (i) may only retroactively deny reimbursement for services subject 24
556+to coordination of benefits with another carrier, the Maryland Medical Assistance Program, 25
557+or the Medicare Program during the 18–month period after the date that the carrier paid 26
558+the health care provider; and 27
582559
583- (G) (H) “PARTICIPANT” MEANS AN EMPLOYEE OR AN EMPLOYEE ’S
584-DEPENDENT WHO PARTIC IPATES IN A SELF–FUNDED GROUP HEALTH INSURANCE
585-PLAN.
560+ (ii) except as provided in item (i) of this paragraph, may only 28
561+retroactively deny reimbursement during the 6–month period after the date that the carrier 29
562+paid the health care provider. 30
586563
587- (H) (I) “SET OF HEALTH CARE PR ACTITIONERS” HAS THE MEANING
588-STATED IN § 15–113 OF THIS TITLE.
564+ (2) (i) A carrier that retroactively denies reimbursement to a health 31
565+care provider under paragraph (1) of this subsection shall provide the health care provider 32
566+with a written statement specifying the basis for the retroactive denial. 33 SENATE BILL 834 13
589567
590-15–2102.
591568
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:
595569
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 ;
570+ (ii) If the retroactive denial of reimbursement results from 1
571+coordination of benefits, the written statement shall provide the name and address of the 2
572+entity acknowledging responsibility for payment of the denied claim. 3
599573
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 CARE PRACTITIONERS ’
602-CONTRACT AND RENDERE D BY THE HEALTH CARE PRACTITIONER OR SET OF
603-HEALTH CARE PRACTITI ONERS; AND
574+SUBTITLE 21. CAPITATED PAYMENTS. 4
604575
605- (3) PAID PERIODICALLY RE GARDLESS OF UTILIZAT ION OF THE
606-SERVICES BY THE MEMB ERS OR PARTICIPANTS .
576+15–2101. 5
607577
608- (B) SUBJECT TO THE REQUIR EMENTS OF SUBS ECTION (C) OF THIS SECTION,
609-A HEALTH CARE PRACTI TIONER OR SET OF HEA LTH CARE PRACTITIONE RS IS NOT Ch. 298 2022 LAWS OF MARYLAND
578+ (A) IN THIS SUBTITLE THE FOLLOWING WORDS HAVE THE MEANINGS 6
579+INDICATED. 7
610580
611-– 14 –
612-ENGAGED IN INSURANCE BUSINESS AS DESCRIBE D 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 PRACT ITIONERS.
581+ (B) “ADMINISTRATOR ” MEANS A CARRIER ADMI NISTERING A SELF–FUNDED 8
582+GROUP HEALTH PLAN . 9
617583
618- (C) A HEALTH CARE PRACTITI ONER OR SET OF HEALT H CARE
619-PRACTITIONERS IS NOT ENGAGED IN INSURANCE BUSINESS AS DESCRIBED 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 OF HEALTH CARE PRACTITIONERS T O
624-MEMBERS OF A SELF –FUNDED GROUP HEALTH PLAN IF:
584+ (C) “CARRIER” HAS THE MEANING STATED IN § 15–113 OF THIS TITLE. 10
625585
626- (1) THE HEALTH CARE PRAC TITIONER OR SET OF H EALTH CARE
627-PRACTITIONERS PARTIC IPATES IN THE ADMINI STRATOR’S NETWORK AND ACCEPT S
628-CAPITATED PAYMENTS ;
586+ (D) “HEALTH BENEFIT PLAN ” HAS THE MEANING STAT ED IN § 2–112.2 OF 11
587+THIS ARTICLE. 12
629588
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
589+ (D) (E) “HEALTH CARE PRACTITIO NER” HAS THE MEANING STAT ED IN § 13
590+15–113 OF THIS TITLE. 14
633591
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.
592+ (E) (F) “MEMBER” HAS THE MEANING STAT ED IN § 15–10A–01 OF THIS 15
593+TITLE. 16
637594
638- (D) NOTWITHSTANDING SUBSE CTIONS (B) AND (C) OF THIS SECTION ,
639-NOTHING IN THIS SECT ION MAY BE CONSTRUED TO:
595+ (F) (G) “NETWORK” HAS THE MEANING STAT ED IN § 15–112 OF THIS 17
596+TITLE. 18
640597
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
598+ (G) (H) “PARTICIPANT” MEANS AN EMPLOYEE OR AN EMPLOYEE ’S 19
599+DEPENDENT WHO PARTIC IPATES IN A SELF–FUNDED GROUP HEALTH INSURANCE 20
600+PLAN. 21
645601
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.
602+ (H) (I) “SET OF HEALTH CARE PRACTITIONERS ” HAS THE MEANING 22
603+STATED IN § 15–113 OF THIS TITLE. 23
649604
650- SECTION 2. AND BE IT FURTHER EN ACTED, 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. 298
605+15–2102. 24
656606
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;
607+ (A) THIS SECTION APPLIES TO ARRANGEMENTS UNDE R AN INSURED A 25
608+HEALTH BENEFIT PLAN OFFERED BY A CARRIER OR A SELF–FUNDED GROUP HEALTH 26
609+INSURANCE PLAN IN WH ICH A CAPITATED PAYM ENT IS: 27
660610
661- (2) quality outcomes of the value–based arrangements;
611+ (1) CALCULATED AS A FIXE D AMOUNT PER MEMBER OR PARTICIPANT 28
612+ASSIGNED OR ATTRIBUT ED TO THE HEALTH CAR E PRACTITIONER OR SE T OF HEALTH 29
613+CARE PRACTITIONERS ; 30 14 SENATE BILL 834
662614
663- (3) the number of complaints made regarding value–based arrangements;
664-and
665615
666- (4) the cost–effectiveness of the value–based arrangements; and
667616
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.
617+ (2) TO COVER THE PROVISI ON OF A SET OF SERVI CES DEFINED IN THE 1
618+HEALTH CARE PRACTITI ONER’S OR SET OF HEALTH CARE PR ACTITIONERS’ 2
619+CONTRACT AND RENDERE D BY THE HEALTH CARE PRACTITIONER OR SET OF 3
620+HEALTH CARE PRACTITI ONERS; AND 4
670621
671- SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect
672-October 1, 2022.
622+ (3) PAID PERIODICALLY RE GARDLESS OF UTILIZAT ION OF THE 5
623+SERVICES BY THE MEMB ERS OR PARTICIPANTS . 6
673624
674-Approved by the Governor, May 12, 2022.
625+ (B) SUBJECT TO THE REQUIR EMENTS OF SUBSECTION (C) OF THIS SECTION, 7
626+A HEALTH CARE PRACTI TIONER OR SET OF HEA LTH CARE PRACTITIONE RS IS NOT 8
627+ENGAGED IN INSURANCE BUSINESS AS DESCRIBE D IN § 4–205 OF THIS ARTICLE 9
628+SOLELY BECAUSE THE H EALTH CARE PRACTITIO NER OR SET OF HEALTH CARE 10
629+PRACTITION ERS ENTERS INTO A CO NTRACT WITH A CARRIE R THAT INCLUDES 11
630+CAPITATED PAYMENTS F OR SERVICES PROVIDED BY THE HEALTH CARE 12
631+PRACTITIONER OR SET OF HEALTH CARE PRACT ITIONERS. 13
632+
633+ (C) A HEALTH CARE PRACTITI ONER OR SET OF HEALT H CARE 14
634+PRACTITIONERS IS NOT ENGAGED IN INS URANCE BUSINESS AS D ESCRIBED IN § 15
635+4–205(C) OF THIS ARTICLE SOLE LY BECAUSE THE HEALT H CARE PRACTITIONER OR 16
636+SET OF HEALTH CARE P RACTITIONERS ENTERS INTO A CONTRACT WITH AN 17
637+ADMINISTRATOR THAT I NCLUDES CAPITATED PA YMENTS FOR SERVICES PROVIDED 18
638+BY THE HEALTH CA RE PRACTITIONER OR S ET OF HEALTH CARE PR ACTITIONERS TO 19
639+MEMBERS OF A SELF –FUNDED GROUP HEALTH PLAN IF: 20
640+
641+ (1) THE HEALTH CARE PRAC TITIONER OR SET OF H EALTH CARE 21
642+PRACTITIONERS PARTIC IPATES IN THE ADMINI STRATOR’S NETWORK AND ACCEPT S 22
643+CAPITATED PAYMENTS ; 23
644+
645+ (2) THE SELF –FUNDED GROUP HEALTH PLAN RETAINS THE 24
646+OBLIGATION TO PROVID E ACCESS TO COVERED HEALTH CARE BENEFITS TO 25
647+PARTICIPANTS; AND 26
648+
649+ (3) THE CONTRACT DOES NO T INCLUDE OTHER REIM BURSEMENT 27
650+ARRANGEMENTS THAT AR E CONSIDERED ACTS OF AN INSURANCE BUSINES S UNDER 28
651+§ 4–205(C) OF THIS ARTICLE. 29
652+
653+ (D) NOTWITHSTANDING SUBSE CTIONS (B) AND (C) OF THIS SECTION , 30
654+NOTHING IN THIS SECT ION MAY BE CONSTRUED TO: 31
655+
656+ (1) ALTER ANY REQUIREMEN T FOR A CARRIER OR S ELF–FUNDED 32
657+GROUP HEALTH PLAN TO PAY A HOSPITAL OR RE LATED INSTITUTION TH E RATE 33
658+APPROVED BY THE HEALTH SERVICES COST REVIEW COMMISSION FOR HOSPIT AL 34
659+SERVICES; OR 35 SENATE BILL 834 15
660+
661+
662+
663+ (2) SUPERSEDE THE HEALTH SERVICES COST REVIEW 1
664+COMMISSION’S JURISDICTION OR AU THORITY OVER RATE RE VIEW AND APPROVAL 2
665+FOR HOSPITAL SERVICE S. 3
666+
667+ SECTION 2. AND BE IT FURTHER ENACTED, That, on or before December 31, 4
668+2023, and annually thereafter until December 31, 2032, the Maryland Health Care 5
669+Commission shall aggregate the following information and report it to the Senate Finance 6
670+Committee and the House Health and Government Operations Committee, in accordance 7
671+with § 2–1257 of the State Government Article: 8
672+
673+ (1) the number and type of value–based arrangements entered into in 9
674+accordance with the authority established under Section 1 of this Act; 10
675+
676+ (2) quality outcomes of the value–based arrangements; 11
677+
678+ (3) the number of complaints made regarding value–based arrangements; 12
679+and 13
680+
681+ (4) the cost–effectiveness of the value–based arrangements; and 14
682+
683+ (5) the impact of two–sided incentive arrangements on the fee schedules of 15
684+health care practitioners included in the target budget that are not eligible providers. 16
685+
686+ SECTION 3. AND BE IT FURTHER ENACTED, That this Act sha ll take effect 17
687+October 1, 2022. 18
688+
689+
690+
691+
692+Approved:
693+________________________________________________________________________________
694+ Governor.
695+________________________________________________________________________________
696+ President of the Senate.
697+________________________________________________________________________________
698+ Speaker of the House of Delegates.