3370

LAWS OF MARYLAND

Ch. 726

(6) (4) PREFERRED PROVIDER POLICIES OR PREFERRED
PROVIDER CONTRACTS OFFERED UNDER THIS SECTION SHALL PROVIDE FOR
PAYMENT OF SERVICES RENDERED BY NONPREFERRED PROVIDERS. UNLESS
THE NONPROFIT HEALTH SERVICE PLAN DEMONSTRATES TO THE
SATISFACTION OF THE INSURANCE COMMISSIONER THAT AN ALTERNATIVE
LEVEL OF PAYMENT IS MORE APPROPRIATE UNDER THE CIRCUMSTANCES, ANY
PAYMENT MADE UNDER THIS PARAGRAPH MAY NOT BE LESS THAN 80% OF THE
AVERAGE PAYMENTS AMOUNT THAT WOULD HAVE BEEN PAID TO PREFERRED
PROVIDERS FOR SIMILAR SERVICES IN THE SAME GEOGRAPHIC AREA.

(C) IF THE RATES FOR EACH INSTITUTIONAL PROVIDER UNDER A
PREFERRED PROVIDER POLICY OR PREFERRED PROVIDER CONTRACT 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.

(D) THIS SECTION DOES NOT APPLY TO ANY EMPLOYEE BENEFIT
PLAN REGULATED BY FEDERAL LAW OR BY THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT OF 1974 (ERISA).

470V.

(A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE
MEANINGS INDICATED.

(2)  "PREFERRED PROVIDER POLICIES OR PREFERRED
PROVIDER CONTRACTS" MEANS INSURANCE POLICIES OR INSURANCE
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 AN INSURER 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 AN INSURER, WHICH IS
PROHIBITED BY §§ 217 THROUGH 234, INCLUSIVE, OF THIS SUBTITLE OR
ANY ACT, METHOD OF COMPETITION, OR PRACTICE NOT SPECIFIED IN §§
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 § 216 OF THIS SUBTITLE.