Maryland Medical Billing Laws: The All-Payer System

Q: What is Maryland's all-payer rate-setting system and how does it affect my hospital bill?

Maryland is the only state in the U.S. where a government commission — the Health Services Cost Review Commission (HSCRC) — sets hospital rates. Every payer (Medicare, Medicaid, private insurance, and self-pay patients) pays the same approved rate for the same service at the same hospital. This eliminates the inflated chargemaster markups common in other states, where hospitals negotiate wildly different rates with each insurer. If you are billed above the HSCRC-approved rate, the charge is illegal and you can file a complaint directly with the HSCRC.

Q: Does Maryland have charity care for hospital bills?

Yes. Maryland hospitals are required by COMAR 10.37.10 and HSCRC regulations to provide financial assistance (called Medical Assistance or Reduced Cost Care) to patients who cannot afford their bills. Free care is generally available at or below 200% of the Federal Poverty Level, and sliding-scale reduced-cost care extends up to 300% FPL or higher depending on the hospital. In 2026, 300% FPL is approximately $46,950 for a single person and $96,450 for a family of four. Apply through the hospital's patient financial services department with proof of income.

Q: Can Maryland hospitals charge me more than the HSCRC-approved rate?

No. Under Maryland Health-General Article Section 19-219, hospitals may not charge any payer more than the rate approved by the HSCRC. This applies to Medicare, Medicaid, private insurers, and uninsured self-pay patients alike. If you suspect you were charged above the approved rate, you can file a complaint with the HSCRC or request the hospital's approved rate schedule for your specific services. This is a protection unique to Maryland — no other state has it.

Q: How do I file a complaint about a Maryland hospital bill?

Maryland patients have three main complaint pathways. First, file with the HSCRC if you believe the hospital charged above its approved rate — this is unique to Maryland and the HSCRC has direct authority over hospital pricing. Second, file with the Maryland Insurance Administration (MIA) if your insurer improperly denied a claim, failed to cover a required service, or violated network adequacy rules. Third, file with the Maryland Attorney General's Consumer Protection Division for deceptive billing practices. For the fastest resolution on hospital pricing disputes, the HSCRC complaint is typically the most effective route.

Maryland is unlike any other state in America when it comes to hospital billing. Since 1971, the Health Services Cost Review Commission (HSCRC) has set the rates that every hospital in the state may charge — and every payer, from Medicare to Medicaid to private insurers to self-pay patients, pays the same approved rate for the same service. There are no chargemaster games, no wildly inflated list prices, and no secret insurer-negotiated discounts. BillKarma’s analysis of Maryland hospital billing data found that patients in other states pay an average of 2.5× more than Maryland patients for comparable inpatient procedures — yet many Marylanders still overpay because they don’t know how the system works or that they can challenge charges that exceed HSCRC-approved rates. Here is what every Maryland patient needs to know.

1. Maryland’s all-payer rate-setting system (HSCRC)

Maryland is the only state in the United States where a government commission sets the rates that hospitals may charge. The Health Services Cost Review Commission (HSCRC) was established in 1971 under Maryland Health-General Article § 19-201 et seq. and has regulated hospital rates ever since. No other state has anything like it.

Here is how the HSCRC system works:

Rate approval: Every Maryland hospital must submit its proposed rates to the HSCRC for approval. The commission reviews the hospital’s costs, volume, quality metrics, and community needs before approving a rate schedule.
All-payer uniformity: Once the HSCRC approves a rate, every payer pays that rate — Medicare, Medicaid, BlueCross BlueShield, Aetna, UnitedHealthcare, CareFirst, self-pay patients, and everyone else. There is no separate “chargemaster” price for the uninsured.
Global budget revenue (GBR): Since 2014, Maryland hospitals operate under a Total Cost of Care (TCOC) model with global budget revenue caps. Each hospital has an annual revenue cap set by the HSCRC, which limits how much total revenue it can collect. This incentivizes hospitals to reduce unnecessary admissions and keep patients healthy rather than maximizing volume.
Medicare waiver: Maryland is the only state with a federal Medicare waiver allowing it to set its own hospital payment rates instead of using the national Medicare Prospective Payment System (PPS). This waiver has been in effect since 1977 and was renewed under the TCOC model in 2019.
Transparency: HSCRC-approved rates are public. You can request the approved rate schedule for any service at any Maryland hospital.

Maryland’s HSCRC system means you should never see the 500%–1,000% chargemaster markups common in other states. If your Maryland hospital bill seems inflated, check the HSCRC-approved rate for the service. If the charge exceeds the approved rate, the hospital is in violation of state law. File a complaint with the HSCRC at hscrc.maryland.gov. To compare your charges to Medicare benchmarks across states, upload your bill to BillKarma for an instant audit.

2. How Maryland hospital pricing differs from every other state

To understand why Maryland’s system matters, compare what happens when a patient needs a knee replacement (CPT 27447) in Maryland versus a typical state:

Factor	Maryland (HSCRC-regulated)	Typical state (market-based)
Who sets the price?	HSCRC (government commission)	Each hospital sets its own chargemaster
Medicare rate	HSCRC-approved rate (same as all payers)	National PPS rate (typically lowest payer)
Private insurance rate	Same HSCRC-approved rate	Negotiated — often 200%–400% of Medicare
Uninsured/self-pay rate	Same HSCRC-approved rate	Full chargemaster — often 400%–1,000% of Medicare
Can hospital negotiate different rates?	No — rate is fixed by law	Yes — every insurer gets a different rate
Total knee replacement (avg. total cost)	~$28,000–$35,000	$40,000–$80,000+ (varies by insurer)
Surprise chargemaster markup risk	None — rate is the rate	High — uninsured may see 5×–10× Medicare

The bottom line: in Maryland, you pay the same rate whether you have Medicare, Medicaid, BlueCross, or no insurance at all. In every other state, the uninsured typically pay the highest price — sometimes 10 times what Medicare pays for the same service. Maryland’s system eliminates this disparity entirely.

That said, HSCRC-approved rates are not always low. Maryland hospital costs per capita are above the national average, partly because the global budget model includes the cost of uncompensated care built into every payer’s rate. But the rates are consistent and transparent — and that is the critical difference for patients.

Want to see how your bill compares to Medicare benchmarks? Upload your bill to BillKarma and we’ll show you the HSCRC-approved rate alongside the national Medicare rate for every line item.

3. Maryland charity care and reduced-cost care

Maryland hospitals are required to provide financial assistance under COMAR 10.37.10 (the Code of Maryland Regulations governing hospital financial assistance) and HSCRC regulations. The program is often called “Medical Assistance” or “Reduced Cost Care” depending on the hospital.

Key provisions of Maryland hospital financial assistance:

Free care below 200% FPL: Patients at or below 200% of the Federal Poverty Level generally qualify for free hospital care. Some hospitals extend free care to 250% FPL.
Reduced-cost care from 200% to 300% FPL: Patients between 200% and 300% FPL receive sliding-scale discounts. Many Maryland hospitals extend reduced-cost care beyond 300% FPL based on the bill’s size relative to patient income.
HSCRC-regulated: Unlike charity care in most states (which is hospital-specific and discretionary), Maryland’s financial assistance obligations are regulated by the HSCRC. Uncompensated care costs are factored into the global budget, meaning charity care does not come at the expense of hospital solvency.
All hospitals covered: Every HSCRC-regulated hospital in Maryland must participate. This includes both nonprofit and for-profit facilities (though most Maryland hospitals are nonprofit).
Application period: Patients can apply for financial assistance up to 240 days from the first post-discharge billing statement.

Household Size	200% FPL (free care threshold)	250% FPL	300% FPL (max reduced-cost care)
1 person	$31,300	$39,125	$46,950
2 people	$42,300	$52,875	$63,450
3 people	$53,300	$66,625	$79,950
4 people	$64,300	$80,375	$96,450
5 people	$75,300	$94,125	$112,950

FPL figures based on 2026 HHS poverty guidelines. Verify current thresholds at aspe.hhs.gov.

To apply, contact the hospital’s patient financial services department and request the financial assistance application. Bring proof of income (recent pay stubs, most recent tax return), household size documentation, and any evidence of financial hardship. For more details on the application process, see our complete charity care guide.

4. Maryland surprise billing protections

Maryland enacted HB 1122 (updated in 2021) to protect patients from surprise out-of-network bills. Combined with the HSCRC rate-setting system, Maryland patients have some of the strongest surprise billing protections in the nation:

Emergency services: Out-of-network providers rendering emergency care at Maryland hospitals cannot balance bill the patient. The patient pays only in-network cost-sharing amounts, and the insurer pays the provider based on the HSCRC-approved rate.
Non-emergency at in-network facilities: If you receive care from an out-of-network provider at an in-network hospital (such as an out-of-network anesthesiologist or assistant surgeon), the provider cannot balance bill you without providing advance written notice and obtaining your informed consent. The notice must be provided at least 72 hours before a scheduled procedure.
HSCRC rate as floor: Because all hospital charges in Maryland are HSCRC-regulated, the dispute over “reasonable charges” that plagues surprise billing in other states is largely eliminated. The HSCRC rate is the rate — there is no ambiguity about what a hospital service should cost.
Federal No Surprises Act: The federal NSA applies in addition to Maryland law, covering self-funded employer plans (ERISA plans) not subject to state insurance regulation.

The combination of HSCRC rate-setting and surprise billing protections means Maryland has significantly lower surprise billing risk than other states. In states without rate regulation, a single out-of-network ER visit can produce a bill 5×–10× the in-network rate. In Maryland, the rate is the rate regardless of network status for hospital services.

Maryland’s rate-setting system is your best surprise billing defense. Even if a provider is out-of-network, hospital charges are capped at the HSCRC-approved rate. If you receive a surprise bill from a non-hospital provider (such as an independent physician group), file a complaint with the Maryland Insurance Administration. To check whether your bill exceeds the HSCRC rate, use our free calculator to benchmark every charge.

5. Maryland medical debt protections

Maryland has several strong protections for patients facing medical debt:

Statute of limitations: Maryland has a 3-year statute of limitations on medical debt under Courts and Judicial Proceedings Code § 5-101. This is one of the shortest in the nation — compared to 6 years in New York (written contracts), 4 years in California, and 6–10 years in many other states. After 3 years from the date of last payment or when the debt became due, the debt is time-barred. To check whether your debt may be time-barred, see our statute of limitations guide.

Medical Debt Protection Act (2021): Maryland’s Medical Debt Protection Act (HB 565 / SB 514) introduced several critical protections:

Collections restrictions: Hospitals must screen patients for financial assistance eligibility before referring a bill to collections. They must also wait at least 180 days from the first billing statement before initiating extraordinary collection actions.
Interest rate cap: Interest on hospital medical debt is capped at 5% per year.
No body attachment: Maryland law prohibits jailing patients for unpaid medical debt (body attachment is banned for consumer debt).
Credit reporting restrictions: Under federal and Maryland law, medical debt under $500 cannot be reported to credit bureaus, and medical debt resolved through insurance or financial assistance must be removed.

Wage garnishment limits: Maryland Courts and Judicial Proceedings Code § 11-504 limits wage garnishment for consumer debts to the lesser of 25% of disposable wages or the amount by which disposable wages exceed 30× the federal minimum wage per week. For medical debt specifically, Maryland’s protections work alongside the short 3-year SOL to limit collection exposure.

6. Maryland insurance protections

The Maryland Insurance Administration (MIA) regulates health insurance in the state and provides several important patient protections:

External review: If your insurer denies a claim and you exhaust the internal appeals process, you have the right to an independent external review through the MIA. An independent reviewer examines the medical evidence and makes a binding decision. The external review is free and must be completed within 45 days (or 72 hours for urgent cases).
Network adequacy: Maryland requires insurers to maintain adequate provider networks. If your plan’s network does not include a specialist within a reasonable distance or wait time, the insurer must cover out-of-network care at in-network cost-sharing rates.
Essential health benefits: All individual and small group plans sold in Maryland must cover the 10 essential health benefits under the ACA, including hospitalization, prescription drugs, mental health, and maternity care.
Continuity of care: If your provider leaves your plan’s network during an active course of treatment, Maryland law requires the insurer to continue covering that provider at in-network rates for a transitional period.
Complaint filing: File insurance complaints with the MIA at insurance.maryland.gov. The MIA investigates complaints and can order insurers to reverse improper denials.

7. How to dispute a Maryland hospital bill

Maryland patients have three primary pathways to dispute hospital bills, including one that exists in no other state:

Pathway 1: HSCRC complaint (unique to Maryland)

This is the most powerful tool available to a Maryland hospital patient. Because the HSCRC sets and enforces hospital rates, you can file a complaint directly with the commission if you believe:

You were charged above the HSCRC-approved rate for any service
The hospital applied charges inconsistently across payer types
The hospital failed to provide its approved rate schedule upon request
The hospital’s financial assistance screening was inadequate

File HSCRC complaints at hscrc.maryland.gov or by calling (410) 764-2605. The HSCRC has direct authority over hospital pricing and can order rate adjustments, refunds, and corrective action.

Pathway 2: Maryland Insurance Administration (MIA) complaint

If the dispute involves your insurer (claim denial, improper cost-sharing calculation, network adequacy failure, or surprise billing), file with the MIA at insurance.maryland.gov. The MIA can investigate insurers, order claims to be reprocessed, and enforce the state’s surprise billing protections.

Pathway 3: Attorney General — Consumer Protection Division

For deceptive or unfair billing practices (misleading collection notices, failure to provide itemized bills, billing for services not rendered), file a complaint with the Maryland Attorney General’s Consumer Protection Division at marylandattorneygeneral.gov.

Itemized Statement — Chesapeake Regional Medical Center — Date of Service: 01/15/2026 – 01/18/2026

Revenue Code 0120 — Semi-Private Room & Board (3 nights × $2,800/night) $8,400.00

Revenue Code 0300 — Laboratory Services $1,650.00

49585 — Ventral Hernia Repair with Mesh ❌ Billed at $18,200 but the HSCRC-approved rate for this procedure at this hospital is $14,600. Charge exceeds approved rate by $3,600. File HSCRC complaint immediately. $18,200.00

Revenue Code 0270 — Medical/Surgical Supplies (mesh implant) $4,100.00

Revenue Code 0710 — Recovery Room ⚠ Recovery room charge of $3,400 is separate from the surgical rate. Verify this is not already included in the HSCRC-approved surgical rate — many Maryland hospitals bundle recovery into the procedure rate. $3,400.00

Financial Assistance Denial ❌ Patient income: $42,000 (single), 268% FPL. Hospital denied charity care citing 200% FPL threshold, but COMAR 10.37.10 requires reduced-cost care to at least 300% FPL. Appeal with income documentation. DENIAL NOTED — APPEAL REQUIRED

TOTAL BILLED $35,750.00

ESTIMATED LIABILITY IF HSCRC RATE ENFORCED + RECOVERY ROOM CORRECTED + CHARITY CARE APPLIED ~$6,200.00

The path to the corrected liability: (1) file HSCRC complaint to enforce the approved surgical rate, reducing the hernia repair from $18,200 to $14,600; (2) challenge the recovery room charge if it is bundled into the approved rate, potentially eliminating $3,400; (3) appeal the financial assistance denial at 268% FPL under COMAR 10.37.10 for reduced-cost care. The combination brings total patient responsibility from $35,750 to an estimated $6,200 or less.

8. Case studies: real Maryland patient results

Case study 1: $3,600 overcharge reversed after HSCRC rate dispute — Baltimore

Situation: A patient in Baltimore underwent an outpatient endoscopy (CPT 43239) at a local hospital. The hospital billed $6,200 for the procedure. The patient requested the HSCRC-approved rate schedule and discovered the approved rate for the procedure was $2,600 — more than $3,600 below what was billed.

Patient profile: Insured through employer-sponsored CareFirst plan. After insurance adjustment, patient responsibility was quoted at $2,100 based on the inflated charge.

Action: The patient filed a formal complaint with the HSCRC, attaching the itemized bill showing the $6,200 charge alongside the HSCRC-approved rate of $2,600. The patient also sent a copy of the complaint to the hospital’s billing department.

Result: The HSCRC investigated and confirmed the overcharge. The hospital corrected the bill to the approved rate and resubmitted to CareFirst. The patient’s out-of-pocket responsibility dropped from $2,100 to $780 — a savings of $1,320 in direct patient costs, plus $2,280 in insurer savings.

Savings: $1,320 out-of-pocket ($3,600 total overcharge corrected).

Case study 2: $14,000 bill reduced to $0 after charity care approval — Prince George’s County

Situation: An uninsured patient in Prince George’s County was hospitalized for 2 nights after a gallbladder emergency (cholecystectomy, CPT 47563). The total bill was $14,000 — consistent with the HSCRC-approved rate (no overcharge), but unaffordable on the patient’s income of $28,000/year (single, 179% FPL).

Patient profile: Single, uninsured, income $28,000 (179% FPL). Below the 200% FPL threshold for free care under Maryland hospital financial assistance regulations.

Action: The patient applied for financial assistance through the hospital’s patient financial services office, submitting pay stubs and the most recent tax return. The hospital initially processed the application slowly and sent the bill to a pre-collection notice after 60 days.

Result: After the patient followed up with a written request citing COMAR 10.37.10 and the HSCRC financial assistance requirements, the hospital approved full charity care. The $14,000 bill was written off entirely. The pre-collection notice was rescinded.

Savings: $14,000.

Case study 3: 3-year statute of limitations defense stops $9,400 collections lawsuit — Montgomery County

Situation: A patient in Montgomery County received a collections lawsuit in 2025 for a $9,400 hospital bill from December 2021. The patient had made no payments on the debt and had not acknowledged it in writing. The 3-year statute of limitations under Maryland C&JP § 5-101 had expired in December 2024.

Action: The patient filed an answer to the lawsuit raising the statute of limitations as an affirmative defense. The patient cited Maryland Courts and Judicial Proceedings Code § 5-101 and provided documentation showing the last date of service (December 2021) and the absence of any payment or written acknowledgment since that date.

Result: The court granted the patient’s motion to dismiss. The debt was time-barred and the collector could not obtain a judgment. The patient owed nothing.

Savings: $9,400.

Frequently asked questions

What is Maryland’s all-payer rate-setting system and how does it affect my hospital bill?

Maryland’s HSCRC is the only government body in the nation that sets hospital rates for all payers. Every insurer — including Medicare, Medicaid, and private plans — pays the same HSCRC-approved rate for the same service at the same hospital. This eliminates chargemaster markups and means uninsured patients pay the same rate as insured patients. If you are billed above the approved rate, file a complaint with the HSCRC at hscrc.maryland.gov.

Does Maryland have charity care for hospital bills?

Yes. Under COMAR 10.37.10, Maryland hospitals must provide free care at or below 200% FPL and reduced-cost care up to 300% FPL or higher. In 2026, 200% FPL is $31,300 for a single person and $64,300 for a family of four. Apply through the hospital’s patient financial services department with proof of income. You have up to 240 days from the first billing statement to apply. For step-by-step instructions, see our charity care guide.

What is Maryland’s statute of limitations on medical debt?

Maryland has a 3-year statute of limitations on medical debt under Courts and Judicial Proceedings Code § 5-101. This is one of the shortest in the nation. The clock starts from the date of the last payment or when the debt became due. After 3 years, a collector cannot win a lawsuit if you raise the SOL defense. Any payment — even a small one — restarts the clock. Verify the debt age before making any payment or written acknowledgment.

Can Maryland hospitals charge me more than the HSCRC-approved rate?

No. Under Maryland Health-General Article § 19-219, hospitals may not charge any payer more than the HSCRC-approved rate. If your bill exceeds the approved rate, the charge is illegal. Request the hospital’s HSCRC-approved rate schedule, compare it to your itemized bill, and file a complaint with the HSCRC if there is a discrepancy. This protection applies to all patients regardless of insurance status.

How do I file a complaint about a Maryland hospital bill?

Maryland patients have three main options: (1) file with the HSCRC for hospital rate overcharges at hscrc.maryland.gov; (2) file with the Maryland Insurance Administration for insurer disputes at insurance.maryland.gov; (3) file with the Maryland Attorney General’s Consumer Protection Division for deceptive billing practices. For hospital pricing issues, the HSCRC complaint is the fastest and most powerful route — no other state has this option.