HARRY HUGHES, Governor                                     3369

CONTRACTS WHICH SPECIFY THE SERVICES AND HOW SERVICES ARE TO BE
COVERED WHEN RENDERED BY PREFERRED AND NONPREFERRED PROVIDERS.

(3) "PREFERRED PROVIDER" MEANS A PROVIDER WHO HAS
CONTRACTED WITH A NONPROFIT HEALTH SERVICE PLAN TO MEET THE TERMS
AND CONDITIONS OFFERED IN THE PREFERRED PROVIDER POLICY OR
PREFERRED PROVIDER CONTRACT.

(4)  "PROVIDER" MEANS ANY PERSON, INCLUDING A
PHYSICIAN OR HOSPITAL, WHO IS LICENSED OR OTHERWISE AUTHORIZED TO
PROVIDE HEALTH CARE SERVICES, WITHIN THE SCOPE OF THE LICENSE OR
AUTHORIZATION.

(5) "NONPREFERRED PROVIDER" MEANS A PROVIDER ELIGIBLE
FOR PAYMENT UNDER A PREFERRED PROVIDER "POLICY OR PREFERRED
PROVIDER CONTRACT, WHO IS NOT A CONTRACTEE UNDER THE PROVISIONS
OF THE INSURANCE POLICY OR INSURANCE CONTRACT.

(6) "UNFAIR DISCRIMINATION" MEANS ANY ACT, METHOD OF
COMPETITION, OR PRACTICE ENGAGED IN BY A NONPROFIT HEALTH SERVICE
PLAN, WHICH IS PROHIBITED BY SECTIONS 217 THROUGH 234, INCLUSIVE,
OF THIS SUBTITLE OR ANY ACT, METHOD OF COMPETITION, OR PRACTICE
NOT SPECIFIED IN SECTIONS 217 THROUGH 234, INCLUSIVE, THAT THE
COMMISSIONER BELIEVES IS UNFAIR OR DECEPTIVE AND WHICH RESULTS IN
THE INSTITUTION OF AN ACTION BY THE COMMISSIONER UNDER SECTION
216 OF THIS SUBTITLE.

(B) (1) SUBJECT TO THE APPROVAL OF THE COMMISSIONER, A
NONPROFIT HEALTH SERVICE PLAN MAY OFFER OR ADMINISTER A HEALTH
BENEFIT PROGRAM UNDER WHICH THE NONPROFIT HEALTH SERVICE PLAN MAY
OFFER PREFERRED PROVIDER POLICIES OR PREFERRED PROVIDER CONTRACTS
THAT LIMIT THE NUMBERS AND TYPES OF PROVIDERS OF HEALTH CARE
SERVICES ELIGIBLE FOR PAYMENT AS PREFERRED PROVIDERS UNDER THE
INSURANCE POLICIES OR INSURANCE CONTRACTS.

(2) A NONPROFIT HEALTH SERVICE PLAN MAY ESTABLISH
TERMS AND CONDITIONS THAT SHALL BE MET BY A PROVIDER IN ORDER TO
QUALIFY FOR PAYMENT AS A PREFERRED PROVIDER UNDER THE INSURANCE
POLICIES OR INSURANCE CONTRACTS.

(3) A PROVIDER THAT AGREES TO THE TERMS AND

CONDITIONS OFFERED BY THE NONPROFIT HEALTH SERVICE PLAN UNDER THE
TERMS OF THE PREFERRED PROVIDER CONTRACT OR POLICY MAY NOT BE
EXCLUDED.

(4) THE TERMS AND CONDITIONS OF PREFERRED PROVIDER
POLICIES OR CONTRACTS MAY NOT UNFAIRLY DISCRIMINATE AGAINST OR
AMONG HEALTH CARE PROVIDERS.

(5)(3) IF A PREFERRED PROVIDER POLICY OR PREFERRED
PROVIDER CONTRACT PROVIDES FOR REIMBURSEMENT FOR ANY SERVICE THAT
IS WITHIN THE LAWFUL SCOPE OF PRACTICE OF A HEALTH CARE PROVIDER
LICENSED UNDER THE HEALTH OCCUPATIONS ARTICLE, ANY PARTICIPANT,
BENEFICIARY, OR OTHER PERSON COVERED BY THE INSURANCE POLICY OR
INSURANCE CONTRACT SHALL BE ENTITLED TO REIMBURSEMENT FOR THAT
SERVICE.