PARRIS N. GLENDENING, Governor

Ch. 199

Article - Health - General

Section 19-710.1

Annotated Code of Maryland

(1996 Replacement Volume and 1996 Supplement)

Preamble

WHEREAS, Section 19-710.1 of the Health - General Article requires HMOs to
file with the Maryland Insurance Administration the schedule of fees which the HMO
pays to providers not under written contract for services rendered to members of the
health maintenance organization; and

WHEREAS, The fee schedules must be based on the usual, reasonable, and
customary payments for similar claims; and

WHEREAS, Section 19-710.1 permits an HMO to base Medicaid fee schedules on
fees for claims to the U.S. Health Care Financing Administration for services rendered
under the Medicaid program; and

WHEREAS, Fee schedules for services rendered to HMO members in the
Medicare program should similarly be permitted to be based on U.S. Health Care
Financing Administration Medicare fees and the rates paid to HMOs for those services;
now, therefore,

SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF
MARYLAND, That the Laws of Maryland read as follows:

Article - Health - General

19-710.1.

(a) (1) In this section the following words have the meanings indicated.

(2) "Enrollee" means a subscriber or member of the health maintenance

organization.

(3) "Covered service" means a health care service included in the benefit
package of the health maintenance organization and rendered to an enrollee of the health
maintenance organization by a health care provider, including a physician or hospital, not
under written contract with the health maintenance organization:

(i) Pursuant to a verbal or written referral by the enrollee's health
maintenance organization or by a provider under written contract with the enrollee's
health maintenance organization; or

(ii) That has been preauthorized or otherwise approved either verbally
or in writing by the enrollee's health maintenance organization or a provider under
written contract with the enrollee's health maintenance organization.

(4) "Adjunct claims documentation" means an abstract of an enrollee's
medical record which describes and summarizes the diagnosis and treatment of, and
services rendered to, the enrollee.

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