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Statutes Text

Article - Insurance




§15–113.

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

        (2)    “Carrier” means:

            (i)    an insurer;

            (ii)    a nonprofit health service plan;

            (iii)    a health maintenance organization;

            (iv)    a dental plan organization; or

            (v)    any other person that provides health benefit plans subject to regulation by the State.

        (3)    “Health care practitioner” means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.

    (b)    A carrier may not reimburse a health care practitioner in an amount less than the sum or rate negotiated in the carrier’s provider contract with the health care practitioner.

    (c)    (1)    In this subsection, “set of health care practitioners” means:

            (i)    a group practice;

            (ii)    a clinically integrated organization established in accordance with Subtitle 19 of this title; or

            (iii)    an accountable care organization established in accordance with 42 U.S.C. § 1395jjj and any applicable federal regulations.

        (2)    This section does not prohibit a carrier from providing bonuses or other incentive–based compensation to a health care practitioner or a set of health care practitioners if the bonus or other incentive–based compensation:

            (i)    does not create a disincentive to the provision of medically appropriate or medically necessary health care services; and

            (ii)    if the carrier is a health maintenance organization, complies with the provisions of § 19–705.1 of the Health – General Article.

        (3)    A bonus or other incentive–based compensation under this subsection:

            (i)    if applicable, shall promote the provision of preventive health care services; or

            (ii)    may reward a health care practitioner or a set of health care practitioners, based on satisfaction of performance measures, if the following is agreed on in writing by the carrier and the health care practitioner or set of health care practitioners:

                1.    the performance measures;

                2.    the method for calculating whether the performance measures have been satisfied; and

                3.    the method by which the health care practitioner or set of health care practitioners may request reconsideration of the calculations by the carrier.

        (4)    Acceptance of a bonus or other incentive–based compensation under this subsection shall be voluntary.

        (5)    A carrier may not require a health care practitioner or a set of health care practitioners to participate in the carrier’s bonus or incentive–based compensation program as a condition of participation in the carrier’s provider network.

        (6)    A health care practitioner, a set of health care practitioners, a health care practitioner’s designee, or a designee of a set of health care practitioners may file a complaint with the Administration regarding a violation of this subsection.

    (d)    (1)    A carrier shall provide a health care practitioner with a copy of:

            (i)    a schedule of applicable fees for up to the fifty most common services billed by a health care practitioner in that specialty;

            (ii)    a description of the coding guidelines used by the carrier that are applicable to the services billed by a health care practitioner in that specialty; and

            (iii)    the information about the practitioner and the methodology that the carrier uses to determine whether to:

                1.    increase or reduce the practitioner’s level of reimbursement; and

                2.    provide a bonus or other incentive–based compensation to the practitioner.

        (2)    Except as provided in paragraph (4) of this subsection, a carrier shall provide the information required under paragraph (1) of this subsection in the manner indicated in each of the following instances:

            (i)    in writing at the time of contract execution;

            (ii)    in writing or electronically 30 days prior to a change; and

            (iii)    in writing or electronically upon request of the health care practitioner.

        (3)    Except as provided in paragraph (4) of this subsection, a carrier shall make the pharmaceutical formulary that the carrier uses available to a health care practitioner electronically.

        (4)    On written request of a health care practitioner, a carrier shall provide the information required under paragraphs (1) and (3) of this subsection in writing.

        (5)    The Administration may adopt regulations to carry out the provisions of this subsection.

    (e)    (1)    A carrier that compensates health care practitioners wholly or partly on a capitated basis may not retain any capitated fee attributable to an enrollee or covered person during an enrollee’s or covered person’s contract year.

        (2)    A carrier is in compliance with paragraph (1) of this subsection if, within 45 days after an enrollee or covered person chooses or obtains health care from a health care practitioner, the carrier pays to the health care practitioner all accrued but unpaid capitated fees attributable to that enrollee or person that the health care practitioner would have received had the enrollee or person chosen the health care practitioner at the beginning of the enrollee’s or covered person’s contract year.



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