EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*sb0437*
SENATE BILL 437
J4 5lr2932
SB 487/24 – FIN CF HB 418
By: Senator Lam
Introduced and read first time: January 21, 2025
Assigned to: Finance
A BILL ENTITLED
AN ACT concerning 1
Health Maintenance Organizations – Payments to Nonparticipating Providers – 2
Reimbursement Rate 3
FOR the purpose of altering the reimbursement rate at which health maintenance 4
organizations are required to pay certain nonparticipating health care providers for 5
services; and generally relating to payments by health maintenance organizations to 6
nonparticipating providers. 7
BY repealing and reenacting, with amendments, 8
Article – Health – General 9
Section 19–710.1 10
Annotated Code of Maryland 11
(2023 Replacement Volume and 2024 Supplement) 12
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 13
That the Laws of Maryland read as follows: 14
Article – Health – General 15
19–710.1. 16
(a) (1) In this section the following words have the meanings indicated. 17
(2) “Adjunct claims documentation” means an abstract of an enrollee’s 18
medical record which describes and summarizes the diagnosis and treatment of, and 19
services rendered to, the enrollee, including, in the case of trauma rendered in a trauma 20
center, an operative report, a discharge summary, a Maryland Ambulance Information 21
Systems form, or a medical record. 22
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(3) “Berenson–Eggers Type of Service Code” means a code in a 1
classification system developed by the Centers for Medicare and Medicaid Services that 2
groups Current Procedural Terminology codes together based on clinical consistency. 3
(4) “Enrollee” means a subscriber or member of a health maintenance 4
organization. 5
(5) “Evaluation and management service” means any ser vice with a 6
Berenson–Eggers Type of Service Code in the category of evaluation and management. 7
(6) “Institute” means the Maryland Institute for Emergency Medical 8
Services Systems. 9
(7) “Medicare Economic Index” means the fixed–weight input price index 10
that: 11
(i) Measures the weighted average annual price change for various 12
inputs needed to produce physician services; and 13
(ii) Is used by the Centers for Medicare and Medicaid Services in the 14
calculation of reimbursement of physician services under Title XVIII of the federal Social 15
Security Act. 16
(8) “Similarly licensed provider” means: 17
(i) For a physician: 18
1. A physician who is board certified or eligible in the same 19
practice specialty; or 20
2. A group physician practice that contains board certified or 21
eligible physicians in the same practice specialty; 22
(ii) For a health care provider that is not a physician, a health care 23
provider that holds the same type of license. 24
(9) (i) “Trauma center” means a primary adult resource center, level I 25
trauma center, level II trauma center, level III trauma center, or pediatric trauma center 26
that has been designated by the institute to provide care to trauma patients. 27
(ii) “Trauma center” includes an out–of–state pediatric facility that 28
has entered into an agreement with the institute to provide care to trauma patients. 29
(10) “Trauma patient” means a patient that is evaluated or treated in a 30
trauma center and is entered into the State trauma registry as a trauma patient. 31
SENATE BILL 437 3
(11) “Trauma physician” means a licensed physician who has been 1
credentialed or designated by a trauma center to provide care to a trauma patient at a 2
trauma center. 3
(b) In addition to any other provisions of this subtitle, for a covered service 4
rendered to an enrollee of a health maintenance organization by a health care provider not 5
under written contract with the health maintenance organization, the health maintenance 6
organization or its agent: 7
(1) Shall pay the health care provider within 30 days after the receipt of a 8
claim in accordance with the applicable provisions of this subtitle; and 9
(2) Shall pay the claim submitted by: 10
(i) A hospital at the rate approved by the Health Services Cost 11
Review Commission; 12
(ii) A trauma physician for trauma care rendered to a trauma 13
patient in a trauma center, at the greater of: 14
1. 140% of the rate paid by the Medicare program, as 15
published by the Centers for Medicare and Medicaid Services, for the same covered service, 16
to a similarly licensed provider; or 17
2. The rate as of January 1, 2001 that the health 18
maintenance organization paid in the same geographic area, as published by the Centers 19
for Medicare and Medicaid Services, for the same covered service, to a similarly licensed 20
provider; and 21
(iii) Any other health care provider: 22
1. For an evaluation and management service, no less than 23
the greater of: 24
A. 125% of the average rate the health maintenance 25
organization paid as of [January 1 of the previous calendar year] JANUARY 31, 2019, in 26
the same geographic area, as defined by the Centers for Medicare and Medicaid Services, 27
for the same covered service, to similarly licensed providers under written contract with 28
the health maintenance organization, INFLATED BY THE CHAN GE IN THE MEDICARE 29
ECONOMIC INDEX FROM 2019 TO THE CURRENT YEAR ; or 30
B. 140% of the rate paid by Medicare, as published by the 31
Centers for Medicare and Medicaid Services, for the same covered service to a similarly 32
licensed provider in the same geographic area as of August 1, 2008, inflated by the change 33
in the Medicare Economic Index from 2008 to the current year; and 34
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2. For a service that is not an evaluation and management 1
service, no less than 125% of the average rate the health maintenance organization paid as 2
of [January 1 of the previous calendar year] JANUARY 31, 2019, in the same geographic 3
area, as defined by the Centers for Medicare and Medicaid Services, to a similarly licensed 4
provider under written contract with the health maintenance organization for the same 5
covered service, INFLATED BY THE CHAN GE IN THE MEDICARE ECONOMIC INDEX 6
FROM 2019 TO THE CURRENT YEAR . 7
(c) For the purposes of subsection (b)(2)(iii) of this section, a health maintenance 8
organization shall calculate the average rate paid to similarly licensed providers under 9
written contract with the health maintenance organization for the same covered service by 10
summing the contracted rate for all occurrences of the Current Procedural Terminology 11
Code for that service and then dividing by the total number of occurrences of the Current 12
Procedural Terminology Code. 13
(d) A health maintenance organization shall disclose, on request of a health care 14
provider not under written contract with the health maintenance organization, the 15
reimbursement rate required under subsection (b)(2)(ii) and (iii) of this section. 16
(e) (1) Subject to paragraph (2) of this subsection, a health maintenance 17
organization may require a trauma physician not under contract with the health 18
maintenance organization to submit appropriate adjunct claims documentation and to 19
include on the uniform claim form a provider number assigned to the trauma physician by 20
the health maintenance organization. 21
(2) If a health maintenance organization requires a trauma physician to 22
include a provider number on the uniform claim form in accordance with paragraph (1) of 23
this subsection, the health maintenance organization shall assign a provider number to a 24
trauma physician not under contract with the health maintenance organization at the 25
request of the physician. 26
(3) A trauma center, on request from a health maintenance organization, 27
shall verify that a licensed physician is credentialed or otherwise designated by the trauma 28
center to provide trauma care. 29
(4) Notwithstanding the provisions of § 19–701(d) of this subtitle, for 30
trauma care rendered to a trauma patient in a trauma center by a trauma physician, a 31
health maintenance organization may not require a referral or preauthorization for a 32
service to be covered. 33
(f) (1) A health maintenance organization may seek reimbursement from an 34
enrollee for any payment under subsection (b) of this section for a claim or portion of a claim 35
submitted by a health care provider and paid by the health maintenance organization that 36
the health maintenance organization determines is the responsibility of the enrollee. 37
SENATE BILL 437 5
(2) The health maintenance organization may request and the health care 1
provider shall provide adjunct claims documentation to assist in making the determination 2
under paragraph (1) of this subsection or under subsection (b) of this section. 3
(g) (1) A health care provider may enforce the provisions of this section by 4
filing a complaint against a health maintenance organization with the Maryland Insurance 5
Administration or by filing a civil action in a court of competent jurisdiction under § 1–501 6
or § 4–201 of the Courts Article. 7
(2) The Maryland Insurance Administration or a court shall award 8
reasonable attorney fees if the complaint of the health care provider is sustained. 9
(h) The Maryland Health Care Commission annually shall review payments to 10
health care providers to determine the compliance of health maintenance organizations 11
with the requirements of this section and report its findings to the Maryland Insurance 12
Administration. 13
(i) The Maryland Insurance Administration may take any action authorized 14
under this subtitle or the Insurance Article, including conducting an examination under 15
Title 2, Subtitle 2 of the Insurance Article, to investigate and enforce a violation of the 16
provisions of this section. 17
(j) In addition to any other penalties under this subtitle, the Commissioner may 18
impose a penalty not to exceed $5,000 on any health maintenance organization which 19
violates the provisions of this section if the violation is committed with such frequency as 20
to indicate a general business practice of the health maintenance organization. 21
(k) The Maryland Insurance Administration, in consultation with the Maryland 22
Health Care Commission, shall adopt regulations to implement this section. 23
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 24
October 1, 2025. 25