Bill > SB416

This bill alters the reimbursement rates that health maintenance organizations (HMOs), which are organizations that provide health insurance, must pay to healthcare providers who are not directly contracted with them. Specifically, for trauma care provided by a trauma physician (a doctor credentialed by a trauma center to treat trauma patients) in a trauma center, the HMO must pay the greater of 140% of what Medicare pays or the rate the HMO paid on January 1, 2001, adjusted for inflation. For other services provided by non-contracted healthcare providers, the bill mandates that HMOs pay at least 125% of the average rate they paid to contracted providers as of January 31, 2019, adjusted for inflation using the Medicare Economic Index (a measure of price changes for physician services). The bill also defines terms like "adjunct claims documentation" (a summary of a patient's medical record), "Berenson-Eggers Type of Service Code" (a coding system for medical services), "enrollee" (an HMO member), "evaluation and management service" (a type of medical service), "Institute" (the Maryland Institute for Emergency Medical Services Systems), "Medicare Economic Index," "similarly licensed provider" (a provider with the same license or specialty), and "trauma center" (a designated facility for trauma care). It also clarifies that HMOs cannot require referrals or preauthorization for trauma care in trauma centers and outlines enforcement mechanisms, including complaints to the Maryland Insurance Administration and civil actions, with potential penalties for violations.

Budget and Finance

https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/SB0416?ys=2026RS