2808

LAWS OF MARYLAND

Ch. 739

insurance contract shall be entitled to reimbursement for that
service.

(4) (I) Preferred provider policies or preferred
provider contracts offered under this section shall provide for
payment of services rendered by nonpreferred 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 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% of the amount that would have been paid AGGREGATE PAYMENTS IN
THAT FULL CALENDAR YEAR to preferred providers for similar
services in the same geographic area PURSUANT TO THE PREFERRED
PROVIDERS' AGREEMENTS TO PROVIDE THE SERVICES.

(II) ALL COPAYMENT AND DEDUCTIBLE PROVISIONS
CONTAINED IN PREFERRED PROVIDER POLICIES OR PREFERRED PROVIDER
CONTRACTS OFFERED UNDER THIS SECTION WHICH ARE APPLICABLE TO

CLAIMS FOR PAYMENT FOR SERVICES RENDERED BY NONPREFERRED

PROVIDERS SHALL BE THE SAME AS THE COPAYMENT AND DEDUCTIBLE
PROVISIONS APPLICABLE TO CLAIM FOR PAYMENT FOR SIMILAR SERVICES
RENDERED BY PREFERRED PROVIDERS.

477FF.

(b) (1) Subject to the approval of the Commissioner, an
insurer may offer or administer a health benefit program under
which the insurer 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)  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)  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.

(4) (I) Preferred provider policies or preferred
provider contracts offered under this section shall provide for
payment of services rendered by nonpreferred providers unless.
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 AGGREGATE
PAYMENTS IN ANY FULL CALENDAR YEAR made under this paragraph TO