Maryland § 15-2102

§ 15-2102.

    (a)    This section applies to arrangements under a health benefit plan offered by a carrier or a self–funded group health insurance plan in which a capitated payment is:

        (1)    calculated as a fixed amount per member or participant assigned or attributed to the health care practitioner or set of health care practitioners;

        (2)    to cover the provision of a set of services defined in the health care practitioner’s or set of health care practitioners’ contract and rendered by the health care practitioner or set of health care practitioners; and

        (3)    paid periodically regardless of utilization of the services by the members or participants.

    (b)    Subject to the requirements of subsection (c) of this section, a health care practitioner or set of health care practitioners is not engaged in insurance business as described in § 4–205 of this article solely because the health care practitioner or set of health care practitioners enters into a contract with a carrier that includes capitated payments for services provided by the health care practitioner or set of health care practitioners.

    (c)    A health care practitioner or set of health care practitioners is not engaged in insurance business as described in § 4–205(c) of this article solely because the health care practitioner or set of health care practitioners enters into a contract with an administrator that includes capitated payments for services provided by the health care practitioner or set of health care practitioners to members of a self–funded group health plan if:

        (1)    the health care practitioner or set of health care practitioners participates in the administrator’s network and accepts capitated payments;

        (2)    the self–funded group health plan retains the obligation to provide access to covered health care benefits to participants; and

        (3)    the contract does not include other reimbursement arrangements that are considered acts of an insurance business under § 4–205(c) of this article.

    (d)    Notwithstanding subsections (b) and (c) of this section, nothing in this section may be construed to:

        (1)    alter any requirement for a carrier or self–funded group health plan to pay a hospital or related institution the rate approved by the Health Services Cost Review Commission for hospital services; or

        (2)    supersede the Health Services Cost Review Commission’s jurisdiction or authority over rate review and approval for hospital services.