MHCC Data Regarding HMO Payments to Non-Participating Providers

Maryland Health-General Article, §19-710.1 specifies a methodology to calculate minimum payment rates that Health Maintenance Organizations (HMOs) must pay to non-contracting (non-trauma) providers that provide a covered evaluation and management (E&M) service to an HMO patient. The Maryland Health Care Commission (MHCC) is required to annually update these minimum payment rates, which are published by the Maryland Insurance Administration.

As specified in the law, E&M services as defined by the Centers for Medicare and Medicaid Services (CMS) in the Berenson-Eggers Type of Services (BETOS) terminology are calculated from the CMS Medicare Physician Fee Schedule that applied in August of 2008, adjusted by the cumulative Medicare Economic Index (MEI) prior to the start of each calendar year. The 2014 MEI is 0.8%. MHCC and the MIA have agreed to modify the methodology in the event that there is a new E&M services code included in the BETOS E&M categories. Fee levels for new codes will be based on the current Medicare Physician Fee Schedule for the geographic region and inflated using the MEI in subsequent years.

MHCC has refreshed earlier calculations using the published annual MEI rates and updated BETOS E&M codes. This Excel file contains an exhibit showing minimum 2015 payment rates, as required under the law. Payment rates are grouped by Medicare localities in Maryland - National Capital (D.C. and Maryland/Virginia suburbs), Baltimore Metro (Baltimore and surrounding counties), and Other Maryland (the rest of the state) - and separate payments are provided for non-facility and facility locations consistent with the CMS Medicare Physician Fee Schedule.

Questions about these calculations should be referred to the MHCC's Srinivas Sridhara at