PARRIS N. GLENDENING, Governor

Ch. 35

EITHER THROUGH DIRECT PAYMENTS TO THE HEALTH CARE PROVIDER OR
THROUGH REIMBURSEMENT TO THE INSURED.

(B) PAYMENTS TO NONPREFERRED PROVIDERS.

(1) A PREFERRED PROVIDER INSURANCE POLICY OFFERED BY AN
INSURER UNDER THIS SUBTITLE SHALL PROVIDE FOR PAYMENT OF SERVICES
RENDERED BY NONPREFERRED PROVIDERS AS PROVIDED IN THIS SUBSECTION.

(2) UNLESS THE INSURER DEMONSTRATES TO THE SATISFACTION OF
THE COMMISSIONER THAT AN ALTERNATIVE LEVEL OF PAYMENT IS MORE
APPROPRIATE, AGGREGATE PAYMENTS MADE IN A FULL CALENDAR YEAR TO
NONPREFERRED PROVIDERS, AFTER ALL DEDUCTIBLE AND COPAYMENT
PROVISIONS HAVE BEEN APPLIED, ON AVERAGE MAY NOT BE LESS THAN 80% OF
THE AGGREGATE PAYMENTS MADE IN THAT FULL CALENDAR YEAR TO PREFERRED
PROVIDERS FOR SIMILAR SERVICES, IN THE SAME GEOGRAPHIC AREA, UNDER
THEIR PROVIDER SERVICE CONTRACTS.

(C) APPROVED RATES FOR INSTITUTIONAL PROVIDERS.

(1) IN THIS SUBSECTION, "UNFAIR DISCRIMINATION" MEANS AN ACT,
METHOD OF COMPETITION, OR PRACTICE ENGAGED IN BY AN INSURER:

(I) THAT IS PROHIBITED BY TITLE 27, SUBTITLE 2 OF THIS

ARTICLE; OR

(II) THAT, ALTHOUGH NOT SPECIFIED IN TITLE 27, SUBTITLE 2 OF
THIS ARTICLE, THE COMMISSIONER BELIEVES IS UNFAIR OR DECEPTIVE AND THAT
RESULTS IN THE INSTITUTION OF AN ACTION BY THE COMMISSIONER UNDER §
27-104 OF THIS ARTICLE.

(2) IF THE RATES FOR EACH INSTITUTIONAL PROVIDER UNDER A
PREFERRED PROVIDER INSURANCE POLICY OFFERED BY AN INSURER VARY BASED
ON INDIVIDUAL NEGOTIATIONS, GEOGRAPHIC DIFFERENCES, OR MARKET
CONDITIONS AND ARE APPROVED BY THE HEALTH SERVICES COST REVIEW
COMMISSION, THE RATES DO NOT CONSTITUTE UNFAIR DISCRIMINATION UNDER
THIS ARTICLE.

REVISOR'S NOTE: This section is new language derived without substantive
change from former Art. 48A, §§ 657 and 655(k).

In subsection (b)(1) of this section, the reference to this "subsection" is
substituted for the former reference to this "section" for accuracy.

In subsection (b)(2) of this section, the defined term "provider service
contract[s]" is substituted for the former reference to "provider service
agreements" for consistency with the terminology used throughout this
subtitle.

Also in subsection (b)(2) of this section, the former phrase "under the
circumstances" is deleted as surplusage.

Also in subsection (b)(2) of this section, the former reference to payments

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