Learn About Maryland SBL
The Maryland SBL
The Maryland SBL became effective January 1, 2018. Maryland employs an All-Payer Model Agreement to determine reimbursement to OON medical providers. Similar to states that employ APCD’s, Maryland through the All-Payer Model Agreement considers Medicaid and Medicare payments as relevant inputs to what is fair and reasonable reimbursement. Title 19, Subtitle 2, Part II (Health Care Facility Rate Setting) of Maryland’s Health-General Article; § 14-205.2 of the Maryland Insurance Article.
According to CMS,
Based on the survey response and CMS communications with the Maryland Insurance Administration and the Consumer Protection Division of the Maryland Office of the Attorney General staff, CMS understands that Maryland has an applicable All-Payer Model Agreement that would determine the out-of-network rate for hospital services in Maryland (Title 19, Subtitle 2, Part II (Health Care Facility Rate Setting) of Maryland’s Health-General Article). CMS understands that § 19-710.1 of the Health General Article also applies as a specified state law for purposes of determining the out-of-network rate with respect to covered services furnished to individuals in HMOs in Maryland by health care providers who are not under contract with the HMO. CMS also understands that § 14-205.2 of the Maryland Insurance Article is a specified state law that will apply for purposes of determining the out-of-network rate with respect to covered services furnished to individuals in EPOs or PPOs in Maryland by nonpreferred on-call and hospital-based physicians who accept assignment of benefits.4 The federal independent dispute resolution process under sections 2799A-1(c) and 2799A-2(b) of the PHS Act and 45 CFR 149.510 and 149.520 will apply for purposes of determining the out-of-network rate with respect to any items and services and nonparticipating providers, nonparticipating emergency facilities, and nonparticipating providers of air ambulance services to which Maryland’s All-Payer Model Agreement or specified state laws do not apply. The Maryland Insurance Administration will enforce the outcome of the federal independent dispute resolution process for such cases in Maryland.
Letter from CMS to Governor of Maryland, dated May 18, 2022.