Health Maintenance Organizations - Payments to Nonparticipating Providers - Reimbursement Rate
HB 737 would change how Maryland health maintenance organizations (HMOs) must reimburse nonparticipating health care providers for covered services. The bill keeps the existing framework that requires prompt payment and sets different reimbursement rules depending on the type of provider and service, but it updates the benchmark for most noncontracted provider payments. For evaluation and management services and other non-evaluation services, the bill replaces the current comparison to the average contracted rate as of January 1 of the previous calendar year with a fixed January 31, 2019 baseline, then inflates that amount by the change in the Medicare Economic Index to the current year. The bill also preserves the alternative Medicare-based floor for evaluation and management services, and retains the special reimbursement rule for trauma physicians treating trauma patients in trauma centers.
The bill also preserves and clarifies several administrative and enforcement provisions. HMOs would still have to disclose the applicable reimbursement rate on request, may request adjunct claims documentation, and may seek reimbursement from enrollees for amounts determined to be the enrollee’s responsibility. Providers would continue to have enforcement options through the Maryland Insurance Administration or civil court, with attorney’s fees available if the provider prevails. The Maryland Health Care Commission would continue to review HMO compliance annually, and the Maryland Insurance Administration would retain enforcement authority, including the ability to impose a civil penalty for repeated violations. The act would take effect October 1, 2026.
Overall, the bill appears aimed at increasing or stabilizing reimbursement for out-of-network providers by tying payment standards to an older baseline and indexing them forward, rather than resetting the benchmark each year. This could raise HMO payment obligations for certain services, especially where current contracted rates have grown since 2019. It would affect HMOs, nonparticipating physicians and other providers, trauma centers, and patients whose claims may be subject to balance-billing or reimbursement disputes.
Because there are no committee transcripts or recorded votes provided, the bill’s sentiment cannot be measured from debate or floor action. Based on the text alone, the measure appears provider-friendly and likely intended to address reimbursement adequacy and predictability for noncontracted care. The main point of potential contention is the cost impact on HMOs and, indirectly, premiums or network contracting, since the bill would require payments based on a fixed historical benchmark adjusted by the Medicare Economic Index rather than a more current contracted-rate comparison.
HB 737 would amend § 19-710.1 of the Health – General Article governing HMO payments to nonparticipating providers. The bill changes the reimbursement formula for most out-of-network services by anchoring the contracted-rate comparison to January 31, 2019 and indexing it forward using the Medicare Economic Index, while leaving intact the separate trauma physician and hospital payment rules. It would also preserve enforcement mechanisms through the Maryland Insurance Administration, the Maryland Health Care Commission, and private civil actions, and it would continue to authorize penalties for repeated violations.
No committee testimony or vote history was provided, so there is no recorded public sentiment to summarize from the legislative process. Based on the bill text, the measure appears generally supportive of provider reimbursement and likely favorable to nonparticipating physicians and other health care providers. The absence of recorded opposition or support in the supplied materials means any broader political sentiment is not discernible from the available context.
The likely point of contention is the reimbursement increase or shift in payment methodology for HMOs, which insurers may view as raising costs and potentially affecting premiums or network negotiations. Providers, especially nonparticipating physicians and trauma physicians, would likely support the bill because it strengthens payment floors and preserves enforcement tools. The fixed 2019 baseline plus Medicare Economic Index adjustment is the central policy choice that could draw debate, since it may produce higher payments than a year-to-year comparison to current contracted rates.