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<section article="gin" article_name="Insurance" number="15-2102" title_number="15" title_name="Health Insurance" subtitle_number="21" subtitle_name="Capitated Payments">
  <level label="a">
    <text>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:</text>
    <level label="1">
      <text>calculated as a fixed amount per member or participant assigned or attributed to the health care practitioner or set of health care practitioners;</text>
    </level>
    <level label="2">
      <text>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</text>
    </level>
    <level label="3">
      <text>paid periodically regardless of utilization of the services by the members or participants.</text>
    </level>
  </level>
  <level label="b">
    <text>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.</text>
  </level>
  <level label="c">
    <text>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:</text>
    <level label="1">
      <text>the health care practitioner or set of health care practitioners participates in the administrator’s network and accepts capitated payments;</text>
    </level>
    <level label="2">
      <text>the self–funded group health plan retains the obligation to provide access to covered health care benefits to participants; and</text>
    </level>
    <level label="3">
      <text>the contract does not include other reimbursement arrangements that are considered acts of an insurance business under § 4–205(c) of this article.</text>
    </level>
  </level>
  <level label="d">
    <text>Notwithstanding subsections (b) and (c) of this section, nothing in this section may be construed to:</text>
    <level label="1">
      <text>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</text>
    </level>
    <level label="2">
      <text>supersede the Health Services Cost Review Commission’s jurisdiction or authority over rate review and approval for hospital services.</text>
    </level>
  </level>
</section>
