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<section article="gin" article_name="Insurance" number="14-201" future_version_removed="true" title_number="14" title_name="Entities That Act as Health Insurers" subtitle_number="2" subtitle_name="Preferred Provider Organizations">
  <level label="a">
    <text>In this subtitle the following words have the meanings indicated.</text>
  </level>
  <level label="b">
    <text>“Allowed amount” means the dollar amount that an insurer determines is the value of the health care service provided by a provider before any cost sharing amounts are applied.</text>
  </level>
  <level label="c">
    <text>“Assignment of benefits” means the transfer of health care coverage reimbursement benefits or other rights under a preferred provider insurance policy by an insured.</text>
  </level>
  <level label="d">
    <text>“Balance bill” means the difference between a nonpreferred provider’s bill for a health care service and the insurer’s allowed amount.</text>
  </level>
  <level label="e">
    <text>“Cost sharing amounts” means the amounts that an insured is responsible for under a preferred provider insurance policy, including any deductibles, coinsurance, or copayments.</text>
  </level>
  <level label="f">
    <text>“Covered service” means a health care service that is a covered benefit under a preferred provider insurance policy.</text>
  </level>
  <level label="g">
    <text>“Health care services” has the meaning stated in § 19–701 of the Health – General Article.</text>
  </level>
  <level label="h">
    <text>“Hospital–based physician” means:</text>
    <level label="1">
      <text>a physician licensed in the State who is under contract to provide health care services to patients at a hospital; or</text>
    </level>
    <level label="2">
      <text>a group physician practice that includes physicians licensed in the State that is under contract to provide health care services to patients at a hospital.</text>
    </level>
  </level>
  <level label="i">
    <text>“Insured” means a person covered for benefits under a preferred provider insurance policy offered or administered by an insurer.</text>
  </level>
  <level label="j">
    <text>“Medicare economic index” means the fixed–weight input price index that:</text>
    <level label="1">
      <text>measures the weighted average annual price change for various inputs needed to produce physician services; and</text>
    </level>
    <level label="2">
      <text>is used by the Centers for Medicare and Medicaid Services in the calculation of reimbursement of physician services under Title XVIII of the federal Social Security Act.</text>
    </level>
  </level>
  <level label="k">
    <text>“Nonpreferred provider” means a provider that is eligible for payment under a preferred provider insurance policy, but that is not a preferred provider under the applicable provider service contract.</text>
  </level>
  <level label="l">
    <text>“On–call physician” means a physician who:</text>
    <level label="1">
      <text>has privileges at a hospital;</text>
    </level>
    <level label="2">
      <text>is required to respond within an agreed upon time period to provide health care services for unassigned patients at the request of a hospital or a hospital emergency department; and</text>
    </level>
    <level label="3">
      <text>is not a hospital–based physician.</text>
    </level>
  </level>
  <level label="m">
    <text>“Preferential basis” means an arrangement under which the insured or subscriber under a preferred provider insurance policy is entitled to receive health care services from preferred providers at no cost, at a reduced fee, or under more favorable terms than if the insured or subscriber received similar services from a nonpreferred provider.</text>
  </level>
  <level label="n">
    <text>“Preferred provider” means a provider that has entered into a provider service contract.</text>
  </level>
  <level label="o">
    <text>“Preferred provider insurance policy” means:</text>
    <level label="1">
      <text>a policy or insurance contract that is issued or delivered in the State by an insurer, under which health care services are to be provided to the insured by a preferred provider on a preferential basis; or</text>
    </level>
    <level label="2">
      <text>another contract that is offered by an employer, third party administrator, or other entity, under which health care services are to be provided to the subscriber by a preferred provider on a preferential basis.</text>
    </level>
  </level>
  <level label="p">
    <text>“Provider” means a physician, hospital, or other person that is licensed or otherwise authorized to provide health care services.</text>
  </level>
  <level label="q">
    <text>“Provider service contract” means a contract between a provider and an insurer, employer, third party administrator, or other entity, under which the provider agrees to provide health care services on a preferential basis under specific preferred provider insurance policies.</text>
  </level>
  <level label="r">
    <text>“Similarly licensed provider” means:</text>
    <level label="1">
      <text>for a physician:</text>
      <level label="i">
        <text>a physician who is board certified or eligible in the same practice specialty; or</text>
      </level>
      <level label="ii">
        <text>a group physician practice that contains board certified or eligible physicians in the same practice specialty; or</text>
      </level>
    </level>
    <level label="2">
      <text>for a health care provider who is not a physician, a health care provider who holds the same type of license or certification.</text>
    </level>
  </level>
  <level label="s">
    <text>“Subscriber” means a person covered for benefits under a preferred provider insurance policy issued by a person that is not an insurer.</text>
  </level>
</section>
