In this subtitle the following words have the meanings indicated. “Affiliation period” means a period of time beginning on the date of enrollment and not to exceed 2 months, or 3 months in the case of a late enrollee, during which a health maintenance organization does not collect premium, and coverage issued does not become effective. “Association” or “bona fide association” means an association that: has been actively in existence for at least 5 years; has been formed and maintained in good faith for purposes other than obtaining insurance and does not condition membership on the purchase of association–sponsored insurance; does not condition membership in the association on any health status–related factor relating to an individual, and states so clearly in all membership and application materials; makes health insurance coverage offered through the association available to all members regardless of any health status–related factor relating to the members or individuals eligible for coverage and states so clearly in all membership and application materials; does not make health insurance coverage offered through the association available other than in connection with membership in the association, and states so clearly in all marketing and application materials; and provides and annually updates information necessary for the Commissioner to determine whether or not the association meets the definition of bona fide association before qualifying as an association under this subtitle. “Benefit year” means a calendar year in which a health benefit plan provides coverage for health benefits. “Carrier” means a person that is: an insurer that holds a certificate of authority in the State and provides health insurance in the State; a health maintenance organization that is licensed to operate in the State; a nonprofit health service plan that is licensed to operate in the State; or any other person or organization that provides health benefit plans subject to State insurance regulation. “Church plan” means a plan as defined under § 3(33) of the Employee Retirement Income Security Act of 1974. “Eligible individual” means an individual who applies for or is covered under an individual health benefit plan. “Employer sponsored plan” means an employee welfare benefit plan that provides medical care to employees or their dependents, and is not subject to State regulation in accordance with the federal Employee Retirement Income Security Act of 1974. “Enrollment date” means the date on which: an individual enrolls in a health benefit plan; or the first day of the waiting period before which the individual may enroll. “Governmental plan” means a plan as defined in § 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan. “Grandfathered health plan coverage” has the meaning stated in 45 C.F.R. § 147.140. “Health benefit plan” means a: hospital or medical policy or certificate, including those issued under multiple employer trusts or associations located in Maryland or any other state covering Maryland residents; policy, contract, or certificate issued by a nonprofit health service plan that covers Maryland residents; or health maintenance organization subscriber or group master contract. “Health benefit plan” does not include: one or more, or any combination of the following: coverage only for accident or disability income insurance; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers’ compensation or similar insurance; automobile medical payment insurance; credit–only insurance; and coverage for on–site medical clinics; the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of a plan: limited scope dental or vision benefits; and benefits for long–term care, nursing home care, home health care, community–based care, or any combination of these benefits; coverage only for a specified disease or illness if offered as independent, noncoordinated benefits; hospital indemnity or other fixed indemnity insurance if: offered as independent, noncoordinated benefits; the benefits are paid in a fixed dollar amount per period of hospitalization, illness, or service, regardless of the amount of expenses incurred and of the amount of benefits provided with respect to the event or service under any other health coverage; and a notice is displayed prominently in the application materials, in at least 14 point type, that has the following language in capital letters: “This is a supplement to health insurance and is not a substitute for major medical coverage. Lack of major medical coverage (or other minimum essential coverage) may result in an additional payment with your taxes.”; or the following benefits if offered as a separate insurance policy: Medicare supplemental health insurance (as defined under § 1882(g)(1) of the Social Security Act); coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and similar supplemental coverage provided to coverage under a group health plan if the coverage qualifies for the exception described in 45 C.F.R. § 146.145(b)(5)(i)(C). “Health status–related factor” means a factor related to: health status; medical condition; claims experience; receipt of health care; medical history; genetic information; evidence of insurability including conditions arising out of acts of domestic violence; or disability. “Individual Exchange” has the meaning stated in § 31–101 of this article. “Individual health benefit plan” means: a health benefit plan other than a converted policy or a professional association plan for eligible individuals and their dependents; or a certificate issued to an eligible individual that evidences coverage under a policy or contract issued to a trust or association or other similar group of individuals, regardless of the situs of delivery of the policy or contract, if the eligible individual pays the premium and is not being covered under the policy or contract under either federal or State continuation of benefits provisions. “Individual health benefit plan” does not include short–term limited duration insurance. “Minimum essential coverage” has the meaning stated in 45 C.F.R. § 155.20. “Preexisting condition” means a condition that was present before the date of enrollment for coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date. “Qualified health plan” has the meaning stated in § 31–101 of this article. “Short–term limited duration insurance” means health insurance coverage provided under a policy or contract with a carrier and that: has a policy term that is less than 3 months after the original effective date of the policy or contract; may not be extended or renewed; applies the same underwriting standards to all applicants regardless of whether they have previously been covered by short–term limited duration insurance; and contains the notice required by federal law prominently displayed in the contract and in any application materials provided in connection with enrollment. “Waiting period” means the period of time that must pass before an individual is eligible to be covered for benefits under the terms of a group health benefit plan.

This subtitle applies to all carriers that offer health benefit plans to individuals in the State. This subtitle does not apply to a carrier that offers only conversion policies as required by law. This subtitle does not apply to a carrier that offers health insurance coverage only in connection with group health plans.

In addition to any other requirements under this article, a carrier that offers individual health benefit plans in the State shall: have demonstrated the capacity to administer the individual health benefit plans, including adequate numbers and types of administrative staff; have a satisfactory grievance procedure and ability to respond to calls, questions, and complaints from enrollees or insureds; and design policies to help ensure that enrollees or insureds have adequate access to providers of health care. Except as provided in this subsection and § 31–110(f) of this article, a carrier may not offer individual health benefit plans in the State unless the carrier also offers qualified health plans, as defined in § 31–101 of this article, in the Individual Exchange of the Maryland Health Benefit Exchange in compliance with the requirements of Title 31 of this article. A carrier is exempt from the requirement in paragraph (1) of this subsection if: the reported total aggregate annual earned premium from all individual health benefit plans in the State for the carrier and any other carriers in the same insurance holding company system, as defined in § 7–101 of this article, is less than $10,000,000; or the only individual health benefit plans that the carrier offers in the State are student health plans as defined in 45 C.F.R. § 147.145; the Commissioner determines that the carrier complies with the procedures established under paragraph (3) of this subsection; and when the carrier ceases to meet the requirements for the exemption, the carrier provides to the Commissioner immediate notice and its plan for complying with the requirement in paragraph (1) of this subsection. The Commissioner shall establish procedures for a carrier to submit evidence each year that the carrier meets the requirements necessary to qualify for an exemption under paragraph (2) of this subsection. Notwithstanding the exemption provided in paragraph (2) of this subsection, any carrier that offers a catastrophic plan, as defined by the Affordable Care Act, in the State also must offer at least one catastrophic plan in the Maryland Health Benefit Exchange. Notwithstanding the exemption provided in paragraph (2) of this subsection, the Commissioner, in consultation with the Maryland Health Benefit Exchange: may assess the impact of the exemption provided in paragraph (2) of this subsection and, based on that assessment, alter the limit on the amount of annual premiums that may not be exceeded to qualify for the exemption; and shall make any change in the exemption requirement by regulation.

The actuarial value of benefits provided under individual health insurance coverage shall be calculated based on a standardized population and a set of standardized utilization and cost factors. A carrier shall submit any information the Commissioner may require to support and justify the carrier’s calculations of actuarial values.

In this section, “affiliate” means a person that directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with another person. A carrier may elect not to renew all individual health benefit plans in the State. When a carrier elects not to renew all individual health benefit plans in the State, the carrier: shall give notice of its decision to the affected individuals at least 180 days before the effective date of nonrenewal; at least 30 working days before that notice, shall give notice to the Commissioner; if the carrier has an affiliate in the individual market, shall give notice to each affected individual at least 180 days before the effective date of nonrenewal of the individual’s option to purchase all other individual health benefit plans currently offered by the affiliate of the carrier; and may not write new business for individuals in the State for a 5-year period beginning on the date of notice to the Commissioner. A carrier that offers an individual health benefit plan shall offer an individual health benefit plan to an individual who is nonrenewed by an affiliate of the carrier under subsection (c) of this section on a guarantee issue basis, if the individual applies for coverage no later than 63 days after the effective date of nonrenewal. A carrier that issues coverage under subsection (d) of this section may not rate the coverage on a substandard basis unless the individual was rated on a substandard basis under the prior coverage provided to the individual by the affiliate of the carrier. Subject to paragraph (2) of this subsection, a carrier that issues coverage under subsection (d) of this section shall waive the waiting period for coverage of a preexisting condition to the extent that the individual has satisfied a waiting period under the individual’s prior contract or policy. The carrier that issues coverage under subsection (d) of this section may require the individual to satisfy the remaining part of the waiting period if any part of the waiting period under the individual’s prior contract or policy has not been satisfied, unless the coverage issued under subsection (d) of this section has a shorter waiting period. A health maintenance organization need not offer coverage to an individual who does not live, reside, or work within the health maintenance organization’s approved service areas. A carrier will not be considered to have elected not to renew all individual health benefit plans in the State if the carrier complies with 45 C.F.R. § 147.106(d)(3).

In this section the following words have the meanings indicated. “Plan” means, with respect to a product, the pairing of the health benefits under the product with a particular cost–sharing structure, provider network, and service area. “Product” means a discrete package of health benefits that are offered using a particular product network type within a geographic service area. “Product” comprises all plans offered within the product. “Uniform modification of coverage” means a change to a health benefit plan that meets the criteria stated in 45 C.F.R. § 147.106(e). Changes in benefits made to comply with federal or State requirements are not subject to the plus or minus 2 percentage points referenced in 45 C.F.R. § 147.106(e)(3)(v). The combination of all plans offered with a product constitutes the total service area of the product. With respect to a plan that has been modified at the time of coverage renewal consistent with this section, the plan shall be considered to be the same plan if: the plan has the same cost–sharing structure as before the modification; or any variation in cost sharing: is solely related to changes in cost or utilization of medical care; or is to maintain the same metal level described in § 1302(d) and (e) of the Affordable Care Act; the plan continues to cover a majority of the same service area; and the plan continues to cover a majority of the same provider network. Notwithstanding paragraph (1) of this subsection, the plan shall be considered to be the same plan to the extent that the modifications are: made uniformly and solely as a result of a federal or State requirement; made within a reasonable time period after the imposition or modification of the federal or State requirement; and directly related to the imposition or modification of the federal or State requirement. Except as provided in subsection (f) of this section, a carrier shall renew an individual health benefit plan at the option of the eligible individual. A carrier may not cancel or refuse to renew an individual health benefit plan except: for nonpayment of the required premiums; where the individual has performed an act or practice that constitutes fraud; where the individual has made an intentional misrepresentation of material fact under the terms of the coverage; where the carrier elects not to renew all of its individual health benefit plans in the State in accordance with this article; where the individual no longer resides, lives, or works in the service area, provided that: the coverage is terminated under this provision uniformly without regard to any health status–related factor of covered individuals; and notice of the termination is provided to the individual at least 90 calendar days before the date coverage will be terminated; or for individual health benefit plans that are not grandfathered health plans, as defined in 45 C.F.R. § 147.140, where a carrier discontinues offering a particular product in the individual market, if the carrier: at least 90 days before discontinuation of the product, provides notice of the discontinuation to each individual provided coverage under the product; offers each individual provided coverage under the product the option to purchase any other individual health benefit plan coverage offered by the carrier for individuals in the State; and acts uniformly without regard to any health status–related factor of enrolled individuals or individuals who may become eligible for the coverage. A carrier may make a uniform modification of coverage for a product only at the time of renewal of the health benefit plan. A carrier shall provide notice of renewal or uniform modification of coverage for: grandfathered health plan coverage, at least 60 days before the date the coverage will be renewed; and a health benefit plan that is not grandfathered health plan coverage, before the date of the first day of the next annual open enrollment period, in a form and manner specified by the Secretary of Health and Human Services. A carrier may not cancel or refuse to renew an individual health benefit plan because an eligible individual is entitled to or enrolled in Medicare if the eligible individual is renewing coverage under the same policy or contract of insurance.

The Administration shall provide on its Web site and in printed form on request a list of carriers, including contact information for each carrier, that offer individual health benefit plans in the State.

Except as provided in subsection (c) of this section, a carrier may not increase an individual’s premium on an individual health benefit plan more frequently than once every 12 months. An increase in an individual’s premium described in subsection (a) of this section includes an increase due to the individual moving into a higher age band. A carrier may increase an individual’s premium on an individual health benefit plan more frequently than once every 12 months if the premium increase is due solely to the enrollment of a new family member to the individual health benefit plan of the individual.

In this section the following words have the meanings indicated. “Individual Exchange” has the meaning stated in § 31–101 of this article. “Qualified health plan” has the meaning stated in § 31–101 of this article. “Qualified individual” has the meaning stated in § 31–101 of this article. This section applies to a qualified health plan that is issued on or after January 1, 2014, by a carrier through the Individual Exchange. A qualified health plan subject to this section shall include a grace period provision applicable to a qualified individual who: is receiving advance payments of federal premium tax credits; and fails to pay premiums timely. The grace period provision shall: provide a grace period of 3 consecutive months after the initial premium payment to begin coverage has been paid; apply to qualified health plans renewed in accordance with § 15–1309 of this subtitle without the qualified individual having to pay the first month’s premium following renewal; and be in addition to any other grace period provision required by any other applicable State law. During the grace period, a carrier that issues a qualified health plan subject to this section: shall pay all appropriate claims for services rendered to the qualified individual during the first month of the grace period; may pend claims for services rendered to the qualified individual in the second and third months of the grace period; shall notify the federal Department of Health and Human Services that the qualified individual is in the grace period; and shall notify providers of the possibility that claims may be denied when a qualified individual is in the second and third months of the grace period.

In this section the following words have the meanings indicated. “Dependent” means an individual who is or who may become eligible for coverage under the terms of a health benefit plan because of a relationship with another individual. “Health care practitioner” has the meaning stated in § 1–301 of the Health Occupations Article. “Provider” means a health care practitioner or a health care facility that participates on a health benefit plan’s provider panel. “Qualifying coverage in an eligible employer–sponsored plan” has the meaning stated in 45 C.F.R. § 155.300. Beginning November 15, 2014, unless an alternative date is adopted by the federal Department of Health and Human Services, a carrier that sells health benefit plans to individuals in the State shall establish an annual open enrollment period. The annual open enrollment period for 2014 shall begin on November 15, 2014, and extend through January 15, 2015, unless alternative dates are adopted by the federal Department of Health and Human Services. The annual open enrollment period for years beginning on and after January 1, 2015, shall be: the dates adopted by the federal Department of Health and Human Services; or if authorized by the federal Department of Health and Human Services, the dates adopted by the Exchange. During the annual open enrollment period, an individual shall be permitted to: enroll in a health benefit plan offered by the carrier; discontinue enrollment in a health benefit plan offered by the carrier; or change enrollment in a health benefit plan offered by the carrier to a different health benefit plan offered by the carrier. If an individual enrolls in a health benefit plan offered by the carrier during the annual open enrollment period for 2014, the effective date of coverage shall be: January 1, 2015, if the application is received by the carrier on or before December 15, 2014, unless an alternative date is adopted by the federal Department of Health and Human Services; February 1, 2015, if the application is received by the carrier from December 16, 2014, through January 15, 2015, unless an alternative date is adopted by the federal Department of Health and Human Services; and March 1, 2015, if the application is received by the carrier from January 16, 2015, through February 15, 2015, unless an alternative date is adopted by the federal Department of Health and Human Services. If an individual enrolls in a health benefit plan offered by the carrier during the annual open enrollment period for years beginning on and after January 1, 2015, the effective date of coverage shall be: the date adopted by the federal Department of Health and Human Services; or if authorized by the federal Department of Health and Human Services, the date adopted by the Exchange. A carrier participating in the Individual Exchange shall provide: the special enrollment periods specified in 45 C.F.R. § 155.420 for individuals who purchase coverage through the Individual Exchange; a special enrollment period for an individual who purchases coverage through the Individual Exchange if the individual or a dependent of the individual becomes pregnant, as confirmed by a health care practitioner; and a special enrollment period for an individual who purchases coverage through the Individual Exchange if the individual or a dependent of the individual is: a patient being treated on a regular basis by or at a provider; and enrolled in a health benefit plan in which the provider treating the individual or dependent is terminated from the health benefit plan’s provider panel. A carrier shall provide: the special enrollment periods specified in 45 C.F.R. § 147.104(b)(2) for individuals who purchase coverage outside the Individual Exchange; a special enrollment period for an individual who purchases coverage outside the Individual Exchange if the individual or a dependent of the individual becomes pregnant, as confirmed by a health care practitioner; and a special enrollment period for an individual who purchases coverage outside the Individual Exchange if the individual or a dependent of the individual is: a patient being treated on a regular basis by or at a provider; and enrolled in a health benefit plan in which the provider treating the individual or dependent is terminated from the health benefit plan’s provider panel. A special enrollment period described in subsection (c)(2) or (d)(2) of this section shall: be open for a period of 90 days; and begin on the date the health care practitioner confirms the pregnancy. A special enrollment period described in subsection (c)(3) or (d)(3) of this section shall: be open for a period of 90 days; and begin on: the date of termination of the provider from the health benefit plan’s provider panel; or if the consumer did not receive notice of the termination before the termination date, the date of the notice of termination. If an individual enrolls for coverage during one of the open enrollment periods described in subsection (b) of this section or during one of the special open enrollment periods described in subsections (c)(1) and (d)(1) of this section, coverage shall be effective in accordance with the requirements in 45 C.F.R. § 155.420. If an individual enrolls for coverage or enrolls a dependent for coverage during a special enrollment period described in subsection (c)(2) or (d)(2) of this section, the coverage shall become effective on the first day of the month in which the individual receives confirmation of pregnancy. If an individual enrolls for coverage or enrolls a dependent for coverage during a special enrollment period described in subsection (c)(3) or (d)(3) of this section, the individual shall select if coverage shall become effective: on the first day of the month following the date the health benefit plan was selected; or on the first day of the month in which the termination of the provider on the health benefit plan’s provider panel became effective. A health maintenance organization may: limit the individuals who may apply for coverage to those who live or reside in the health maintenance organization’s service area; and deny coverage to individuals if the health maintenance organization has demonstrated to the Commissioner that: it will not have the capacity to deliver services adequately to any additional individuals because of its obligations to existing enrollees; and it is applying the provisions of this paragraph uniformly to all individuals without regard to the claims experience of those individuals and their dependents or any health status–related factor relating to the individuals and their dependents. A health maintenance organization that denies coverage to an individual in accordance with paragraph (1) of this subsection may not offer coverage in the individual market within the service area to any individual for a period of 180 days after the date the coverage is denied. Paragraph (2) of this subsection does not: limit the health maintenance organization’s ability to renew coverage already in force; or relieve the health maintenance organization of the responsibility to renew coverage already in force. A carrier may deny a health benefit plan to an individual if the carrier has demonstrated to the Commissioner that: it does not have the financial reserves necessary to offer additional coverage; and it is applying the provisions of this paragraph uniformly to all individuals in the individual market in the State without regard to the claims experience of those individuals and their dependents or any health status–related factor relating to the individuals and their dependents. A carrier that denies a health benefit plan to an individual in the State under paragraph (1) of this subsection may not offer coverage in the individual market before the later of: the 181st day after the date the carrier denies coverage; and the date the carrier demonstrates to the Commissioner that the carrier has sufficient financial reserves to underwrite additional coverage. Paragraph (2) of this subsection does not: limit the carrier’s ability to renew coverage already in force; or relieve the carrier of the responsibility to renew coverage already in force. Health benefit plans offered after the time period described in paragraph (2) of this subsection are subject to the requirements of this section.

A carrier that sells health benefit plans to individuals in the State shall establish an initial open enrollment period that begins October 1, 2013, and extends through March 31, 2014. A carrier shall accept all applicants who apply for coverage during the initial open enrollment period. If an application is received by a carrier during the initial open enrollment period, coverage for the applicant shall begin no later than: January 1, 2014, if the application is received on or before December 15, 2013; the first day of the following month, if the application is received between the first and fifteenth day, inclusive, of January, February, or March; and the first day of the second following month, if the application is received between the sixteenth day and the last day, inclusive, of December, January, February, or March.

In this section the following words have the meanings indicated. “Institution of higher education” has the meaning stated in the federal Higher Education Act of 1965. “Student administrative health fee” means a fee charged by an institution of higher education on a periodic basis to students of the institution of higher education to offset the cost of providing health care through health clinics regardless of whether the students utilize the health clinics or enroll in student health plan coverage. “Student health plan” means an individual health benefit plan that is provided to students enrolled in an institution of higher education and their dependents under a written agreement that: is between the institution of higher education and a carrier; does not make coverage under the health benefit plan available other than in connection with enrollment as a student or as a dependent of a student in the institution of higher education; and does not condition eligibility for the health benefit plan on any health status–related factor relating to a student or a dependent of a student. A carrier that offers student health plans is not required to: accept individuals who are not: students; or dependents of students covered under the student health plan; establish open enrollment periods; establish effective dates that are based on a calendar year; offer health benefit plan contracts that are on a calendar year basis; or renew, or continue in force, coverage for individuals who are no longer students or dependents of students. A student health plan is not subject to the requirement of a single risk pool under § 1312(c) of the Affordable Care Act. A student health plan shall comply with the requirements of 45 C.F.R. § 147.145, as interpreted and implemented by the federal Centers for Medicare and Medicaid Services. A student administrative health fee is not considered a cost–sharing requirement with respect to specified recommended preventive services.