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Ch. 243
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Martin O'Malley, Governor
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(2) establish terms and conditions that providers must meet to qualify
for payment as preferred providers.
14-205.
(a) If a preferred provider insurance policy offered by an insurer provides
benefits for a service that is within the lawful scope of practice of a health-care
provider licensed under the Health Occupations Article, an insured covered by the
preferred provider insurance policy is entitled to receive the benefits for that service
either through direct payments to the health care provider or through reimbursement
to the insured.
(B) A PREFERRED PROVIDER INSURANCE POLICY OFFERED BY AN
INSURER MAY PROVIDE FOR PAYMENT OF SERVICES RENDERED BY:
(1) PREFERRED PROVIDERS AND NONPREFERRED PROVIDERS;
OR
(2) PREFERRED PROVIDERS.
[(b)] (C) (1) [A] IF A preferred provider insurance policy offered by an
insurer under this subtitle [shall provide] PROVIDES for payment of services rendered
by nonpreferred providers, THE INSURER SHALL ESTABLISH PAYMENT as provided
(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.
(D) A PREFERRED PROVIDER INSURANCE POLICY SHALL ALLOW
DIRECT ACCESS TO SPECIALISTS.
[(e)] (E) (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.
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- 1667 -
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