Maryland 2025 Regular Session

Maryland Senate Bill SB437 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2
3	3	EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
4	4	[Brackets] indicate matter deleted from existing law.
5	5	sb0437
6	6
7	7	SENATE BILL 437
8	8	J4 5lr2932
9	9	SB 487/24 – FIN CF HB 418
10	10	By: Senator Lam
11	11	Introduced and read first time: January 21, 2025
12	12	Assigned to: Finance
13	13
14	14	A BILL ENTITLED
15	15
16	16	AN ACT concerning 1
17	17
18	18	Health Maintenance Organizations – Payments to Nonparticipating Providers – 2
19	19	Reimbursement Rate 3
20	20
21	21	FOR the purpose of altering the reimbursement rate at which health maintenance 4
22	22	organizations are required to pay certain nonparticipating health care providers for 5
23	23	services; and generally relating to payments by health maintenance organizations to 6
24	24	nonparticipating providers. 7
25	25
26	26	BY repealing and reenacting, with amendments, 8
27	27	Article – Health – General 9
28	28	Section 19–710.1 10
29	29	Annotated Code of Maryland 11
30	30	(2023 Replacement Volume and 2024 Supplement) 12
31	31
32	32	SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 13
33	33	That the Laws of Maryland read as follows: 14
34	34
35	35	Article – Health – General 15
36	36
37	37	19–710.1. 16
38	38
39	39	(a) (1) In this section the following words have the meanings indicated. 17
40	40
41	41	(2) “Adjunct claims documentation” means an abstract of an enrollee’s 18
42	42	medical record which describes and summarizes the diagnosis and treatment of, and 19
43	43	services rendered to, the enrollee, including, in the case of trauma rendered in a trauma 20
44	44	center, an operative report, a discharge summary, a Maryland Ambulance Information 21
45	45	Systems form, or a medical record. 22
46	46	2 SENATE BILL 437
47	47
48	48
49	49	(3) “Berenson–Eggers Type of Service Code” means a code in a 1
50	50	classification system developed by the Centers for Medicare and Medicaid Services that 2
51	51	groups Current Procedural Terminology codes together based on clinical consistency. 3
52	52
53	53	(4) “Enrollee” means a subscriber or member of a health maintenance 4
54	54	organization. 5
55	55
56	56	(5) “Evaluation and management service” means any ser vice with a 6
57	57	Berenson–Eggers Type of Service Code in the category of evaluation and management. 7
58	58
59	59	(6) “Institute” means the Maryland Institute for Emergency Medical 8
60	60	Services Systems. 9
61	61
62	62	(7) “Medicare Economic Index” means the fixed–weight input price index 10
63	63	that: 11
64	64
65	65	(i) Measures the weighted average annual price change for various 12
66	66	inputs needed to produce physician services; and 13
67	67
68	68	(ii) Is used by the Centers for Medicare and Medicaid Services in the 14
69	69	calculation of reimbursement of physician services under Title XVIII of the federal Social 15
70	70	Security Act. 16
71	71
72	72	(8) “Similarly licensed provider” means: 17
73	73
74	74	(i) For a physician: 18
75	75
76	76	1. A physician who is board certified or eligible in the same 19
77	77	practice specialty; or 20
78	78
79	79	2. A group physician practice that contains board certified or 21
80	80	eligible physicians in the same practice specialty; 22
81	81
82	82	(ii) For a health care provider that is not a physician, a health care 23
83	83	provider that holds the same type of license. 24
84	84
85	85	(9) (i) “Trauma center” means a primary adult resource center, level I 25
86	86	trauma center, level II trauma center, level III trauma center, or pediatric trauma center 26
87	87	that has been designated by the institute to provide care to trauma patients. 27
88	88
89	89	(ii) “Trauma center” includes an out–of–state pediatric facility that 28
90	90	has entered into an agreement with the institute to provide care to trauma patients. 29
91	91
92	92	(10) “Trauma patient” means a patient that is evaluated or treated in a 30
93	93	trauma center and is entered into the State trauma registry as a trauma patient. 31
94	94	SENATE BILL 437 3
95	95
96	96
97	97	(11) “Trauma physician” means a licensed physician who has been 1
98	98	credentialed or designated by a trauma center to provide care to a trauma patient at a 2
99	99	trauma center. 3
100	100
101	101	(b) In addition to any other provisions of this subtitle, for a covered service 4
102	102	rendered to an enrollee of a health maintenance organization by a health care provider not 5
103	103	under written contract with the health maintenance organization, the health maintenance 6
104	104	organization or its agent: 7
105	105
106	106	(1) Shall pay the health care provider within 30 days after the receipt of a 8
107	107	claim in accordance with the applicable provisions of this subtitle; and 9
108	108
109	109	(2) Shall pay the claim submitted by: 10
110	110
111	111	(i) A hospital at the rate approved by the Health Services Cost 11
112	112	Review Commission; 12
113	113
114	114	(ii) A trauma physician for trauma care rendered to a trauma 13
115	115	patient in a trauma center, at the greater of: 14
116	116
117	117	1. 140% of the rate paid by the Medicare program, as 15
118	118	published by the Centers for Medicare and Medicaid Services, for the same covered service, 16
119	119	to a similarly licensed provider; or 17
120	120
121	121	2. The rate as of January 1, 2001 that the health 18
122	122	maintenance organization paid in the same geographic area, as published by the Centers 19
123	123	for Medicare and Medicaid Services, for the same covered service, to a similarly licensed 20
124	124	provider; and 21
125	125
126	126	(iii) Any other health care provider: 22
127	127
128	128	1. For an evaluation and management service, no less than 23
129	129	the greater of: 24
130	130
131	131	A. 125% of the average rate the health maintenance 25
132	132	organization paid as of [January 1 of the previous calendar year] JANUARY 31, 2019, in 26
133	133	the same geographic area, as defined by the Centers for Medicare and Medicaid Services, 27
134	134	for the same covered service, to similarly licensed providers under written contract with 28
135	135	the health maintenance organization, INFLATED BY THE CHAN GE IN THE MEDICARE 29
136	136	ECONOMIC INDEX FROM 2019 TO THE CURRENT YEAR ; or 30
137	137
138	138	B. 140% of the rate paid by Medicare, as published by the 31
139	139	Centers for Medicare and Medicaid Services, for the same covered service to a similarly 32
140	140	licensed provider in the same geographic area as of August 1, 2008, inflated by the change 33
141	141	in the Medicare Economic Index from 2008 to the current year; and 34
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143	143
144	144
145	145	2. For a service that is not an evaluation and management 1
146	146	service, no less than 125% of the average rate the health maintenance organization paid as 2
147	147	of [January 1 of the previous calendar year] JANUARY 31, 2019, in the same geographic 3
148	148	area, as defined by the Centers for Medicare and Medicaid Services, to a similarly licensed 4
149	149	provider under written contract with the health maintenance organization for the same 5
150	150	covered service, INFLATED BY THE CHAN GE IN THE MEDICARE ECONOMIC INDEX 6
151	151	FROM 2019 TO THE CURRENT YEAR . 7
152	152
153	153	(c) For the purposes of subsection (b)(2)(iii) of this section, a health maintenance 8
154	154	organization shall calculate the average rate paid to similarly licensed providers under 9
155	155	written contract with the health maintenance organization for the same covered service by 10
156	156	summing the contracted rate for all occurrences of the Current Procedural Terminology 11
157	157	Code for that service and then dividing by the total number of occurrences of the Current 12
158	158	Procedural Terminology Code. 13
159	159
160	160	(d) A health maintenance organization shall disclose, on request of a health care 14
161	161	provider not under written contract with the health maintenance organization, the 15
162	162	reimbursement rate required under subsection (b)(2)(ii) and (iii) of this section. 16
163	163
164	164	(e) (1) Subject to paragraph (2) of this subsection, a health maintenance 17
165	165	organization may require a trauma physician not under contract with the health 18
166	166	maintenance organization to submit appropriate adjunct claims documentation and to 19
167	167	include on the uniform claim form a provider number assigned to the trauma physician by 20
168	168	the health maintenance organization. 21
169	169
170	170	(2) If a health maintenance organization requires a trauma physician to 22
171	171	include a provider number on the uniform claim form in accordance with paragraph (1) of 23
172	172	this subsection, the health maintenance organization shall assign a provider number to a 24
173	173	trauma physician not under contract with the health maintenance organization at the 25
174	174	request of the physician. 26
175	175
176	176	(3) A trauma center, on request from a health maintenance organization, 27
177	177	shall verify that a licensed physician is credentialed or otherwise designated by the trauma 28
178	178	center to provide trauma care. 29
179	179
180	180	(4) Notwithstanding the provisions of § 19–701(d) of this subtitle, for 30
181	181	trauma care rendered to a trauma patient in a trauma center by a trauma physician, a 31
182	182	health maintenance organization may not require a referral or preauthorization for a 32
183	183	service to be covered. 33
184	184
185	185	(f) (1) A health maintenance organization may seek reimbursement from an 34
186	186	enrollee for any payment under subsection (b) of this section for a claim or portion of a claim 35
187	187	submitted by a health care provider and paid by the health maintenance organization that 36
188	188	the health maintenance organization determines is the responsibility of the enrollee. 37
189	189	SENATE BILL 437 5
190	190
191	191
192	192	(2) The health maintenance organization may request and the health care 1
193	193	provider shall provide adjunct claims documentation to assist in making the determination 2
194	194	under paragraph (1) of this subsection or under subsection (b) of this section. 3
195	195
196	196	(g) (1) A health care provider may enforce the provisions of this section by 4
197	197	filing a complaint against a health maintenance organization with the Maryland Insurance 5
198	198	Administration or by filing a civil action in a court of competent jurisdiction under § 1–501 6
199	199	or § 4–201 of the Courts Article. 7
200	200
201	201	(2) The Maryland Insurance Administration or a court shall award 8
202	202	reasonable attorney fees if the complaint of the health care provider is sustained. 9
203	203
204	204	(h) The Maryland Health Care Commission annually shall review payments to 10
205	205	health care providers to determine the compliance of health maintenance organizations 11
206	206	with the requirements of this section and report its findings to the Maryland Insurance 12
207	207	Administration. 13
208	208
209	209	(i) The Maryland Insurance Administration may take any action authorized 14
210	210	under this subtitle or the Insurance Article, including conducting an examination under 15
211	211	Title 2, Subtitle 2 of the Insurance Article, to investigate and enforce a violation of the 16
212	212	provisions of this section. 17
213	213
214	214	(j) In addition to any other penalties under this subtitle, the Commissioner may 18
215	215	impose a penalty not to exceed $5,000 on any health maintenance organization which 19
216	216	violates the provisions of this section if the violation is committed with such frequency as 20
217	217	to indicate a general business practice of the health maintenance organization. 21
218	218
219	219	(k) The Maryland Insurance Administration, in consultation with the Maryland 22
220	220	Health Care Commission, shall adopt regulations to implement this section. 23
221	221
222	222	SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 24
223	223	October 1, 2025. 25
224	224