Ch. 578 LAWS OF MARYLAND

652.

(A) IF A PREFERRED PROVIDER INSURANCE POLICY OFFERED BY
AN INSURER PROVIDES BENEFITS FOR ANY SERVICE THAT IS WITHIN
THE LAWFUL SCOPE OF PRACTICE OF A HEALTH CARE PROVIDER
LICENSED UNDER THE HEALTH OCCUPATIONS ARTICLE, ANY INSURED
COVERED BY THE PREFERRED PROVIDER INSURANCE POLICY SHALL BE
ENTITLED TO RECEIVE THE BENEFITS FOR THAT SERVICE EITHER
THROUGH DIRECT PAYMENTS TO THE PROVIDER OR TO
REIMBURSEMENT TO THE INSURED.

(B) (1) A PREFERRED PROVIDER INSURANCE POLICY OFFERED
BY AN INSURER UNDER THIS SUBTITLE SHALL PROVIDE FOR PAYMENT
OF SERVICES RENDERED BY NONPREFERRED PROVIDERS AS PROVIDED
UNDER THIS SECTION.

(2) UNLESS THE INSURER DEMONSTRATES TO THE
SATISFACTION OF THE INSURANCE COMMISSIONER THAT AN
ALTERNATIVE LEVEL OF PAYMENT IS MORE APPROPRIATE UNDER THE
CIRCUMSTANCES, PAYMENTS AGGREGATE PAYMENTS IN ANY FULL
CALENDAR YEAR MADE UNDER THIS PARAGRAPH TO NONPREFERRED
PROVIDERS AFTER ALL DEDUCTIBLE AND COPAYMENT PROVISIONS
HAVE BEEN APPLIED MAY NOT ON THE AVERAGE BE LESS THAN 80
PERCENT OF THE CORRESPONDING PAYMENTS AGGREGATE PAYMENTS
IN THAT FULL CALENDAR YEAR TO PREFERRED PROVIDERS FOR
SIMILAR SERVICES IN THE SAME GEOGRAPHIC AREA PURSUANT TO THE
PROVIDERS' AGREEMENTS TO PROVIDE THE SERVICES UNDER THEIR
PROVIDER SERVICE AGREEMENTS.

(C) IF THE RATES FOR EACH INSTITUTIONAL PROVIDER UNDER A
PREFERRED PROVIDER INSURANCE POLICY OFFERED BY AN INSURER
VARY BASED UPON INDIVIDUAL NEGOTIATIONS, GEOGRAPHIC
DIFFERENCES, OR MARKET CONDITIONS AND ARE APPROVED BY THE
HEALTH SERVICES COST REVIEW COMMISSION, THE RATES MAY NOT BE
DEEMED TO CONSTITUTE UNFAIR DISCRIMINATION UNDER THIS
ARTICLE.

653.

(A) EACH INSURER AND EACH EMPLOYER, ADMINISTRATOR, OR
OTHER ENTITY THAT ISSUES, DELIVERS, ADMINISTERS, OR OFFERS ANY
PREFERRED PROVIDER INSURANCE POLICY OR OTHER NONINSURANCE
PREFERRED PROVIDER ARRANGEMENT IN THIS STATE SHALL, UPON
REQUEST OF THE COMMISSIONER, FILE WITH THE COMMISSIONER A
WRITTEN SUMMARY DESCRIPTION AND A PROTOTYPE COPY OF:

(1) THE PREFERRED PROVIDER INSURANCE POLICY;

(2) ALL ATTENDANT PROVIDER SERVICE CONTRACTS;

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