HARRY HUGHES, Governor

3371

(B) (1) SUBJECT TO THE APPROVAL OF THE COMMISSIONER, ONE OR
MORE INSURERS AN INSURER, INCLUDING ANY NONPROFIT HEALTH SERVICE
PLAN SPECIFIED UNDER SUBTITLE 20 OF THIS ARTICLE, MAY OFFER OR
ADMINISTER A HEALTH BENEFIT PROGRAM UNDER WHICH THE INSURER OR
INSURERS 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) ANY INSURER OR INSURERS AN INSURER 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 INSURER 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) PROVIDERS OF SERVICE OTHER THAN PHYSICIANS SHALL
HAVE THE SAME OPPORTUNITY TO QUALIFY FOR PAYMENT AS A PREFERRED
PROVIDER UNDER THE POLICIES OR CONTRACTS AS DO PHYSICIANS.

(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.

(6) (4) PREFERRED PROVIDER POLICIES OR PREFERRED
PROVIDER CONTRACTS OFFERED UNDER THIS SECTION SHALL PROVIDE FOR
PAYMENT OF SERVICES RENDERED BY NONPREFERRED PROVIDERS. THE
PAYMENTS MAY OR MAY NOT BE THE SAME AMOUNT PAID TO PREFERRED
PROVIDERS. UNLESS THE INSURER 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).