MHCC Data Regarding HMO Payments to Non-Participating Providers

Maryland law requires the Maryland Health Care Commission (MHCC) to provide health insurance carriers that operate Health Maintenance Organizations (HMOs) in the State with the minimum rates that must be paid for Evaluation and Management services as defined by the Centers for Medicare and Medicaid Services (CMS) in the Berenson-Eggers Type of Services (TOS) terminology.  These rates are calculated from the CMS Medicare payment rates that applied in August of 2008 adjusted by the cumulative Medicare Economic Index (MEI) prior to the start of each new calendar year.  Carriers are required to pay the minimum of 140% of these rates to non-contracting (non-trauma) providers that provide a covered evaluation and management service to an HMO patient. 

In 2013, CMS recognized approximately three dozen new CPT and HCPCS codes and retired approximately two dozen existing codes. Most of the new codes replaced existing longstanding and commonly used behavioral health evaluation and management codes. The new codes are reflected in the Berenson-Eggers TOS in 2013. The statute is very specific that MHCC must use Berenson-Eggers as the source for evaluation and management codes.

MHCC is modifying the methodology for deriving the 140 percent of Medicare fee level for CPT and HCPCS codes to accommodate the new evaluation and management services now included in Berenson-Eggers TOS. Fee levels for codes that existed in 2008 will continue to be constructed according to the current methodology. To derive the fee levels for evaluation services that existed in 2008, MHCC adjusted the 2013 fee previously published by .08 percent, which reflects the change in the MEI from calendar year 2012 to 2013.  The change in the MEI (adjusted for productivity) is based on the market basket update published by CMS for Calendar Year 2013. This approach allows MHCC to continue to capture year-to-year medical inflation for the CPT and HCPCS codes that were activated since 2008. For the new codes, MHCC will use the 2013 Medicare Fee Schedule fee levels multiplied by 140 percent. Inclusion of these codes allows MHCC to meet the requirements of the law that fees for all codes defined as evaluation and management codes under the Berenson-Eggers be set at 140 percent of the Medicare level. The attached EXCEL workbook contains a separate worksheet for each of the Medicare localities in Maryland – Baltimore Metro, National Capital, and Other Maryland. Separate payments are provided for facility and non-facility locations consistent with CMS Medicare Fee Schedule payment rules. 

The MEI adjustment can be referenced here.

Questions should be referred to MHCC staff member Larry Monroe via e-mail at larry.monroe@maryland.gov.