Title 14 — Subtitle 35. Maryland Health Benefit Exchange

Chapter 01. General Provisions

Regulation .01 Compliance with Federal Law.Link Copy Citation

The Maryland Health Benefit Exchange shall comply with all provisions of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), and all associated guidance and regulations hereto and hereafter issued.

Regulation .02 Definitions.Link Copy Citation

In this subtitle, the following terms have the meanings indicated.

Terms Defined.

(1)

“Advance payments of the premium tax credit” means payment of the federal tax credits authorized by 26 U.S.C. §36B and its implementing regulations, which are provided on an advance basis to an eligible individual enrolled in a qualified health plan through the Exchange under §1412 of the Affordable Care Act.

(2)

“Advanced Premium Tax Credit (APTC)” has the meaning stated in 45 CFR §155.20.

(3)

“Affordable Care Act (ACA)” means the Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148), as amended, including by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152), and the regulations issued under it.

(4)

“Authorized carrier” means a carrier that the Exchange certifies is authorized to offer a qualified plan in the Exchange under COMAR 14.35.15.

(5)

“Board” has the meaning stated in Insurance Article, §31-101, Annotated Code of Maryland.

(6)

“Bronze coverage level” means the level of coverage described under §1302(d)(1)(A) of the ACA.

(7)

“CARES” means the case management data system that tracks eligibility for Medicaid and other social services.

(8)

“Carrier” has the meaning set forth in Insurance Article §31-101(c), Annotated Code of Maryland.

(9)

“Catastrophic plan” means a qualified health plan described in §1302(e) of the ACA.

(10)

“Certification standard” means a process, procedure, requirement, or condition of participation in the Exchange under COMAR 14.35.15 or COMAR 14.35.16.

(11)

“Commissioner” means the Maryland Insurance Commissioner.

(12)

Cost Sharing.

(a)

“Cost sharing” means any expenditure required by or on behalf of an enrollee with respect to covered benefits.

(b)

“Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

(c)

“Cost sharing” does not include premiums, balance billing amounts for non-network providers, and spending for non-covered services.

(13)

“Cost-sharing reductions (CSR)” means reductions in cost sharing for an eligible individual enrolled in a silver level plan through the Exchange or for an individual who is an Indian enrolled in a QHP through the Exchange.

(14)

“Coverage” means insurance through which benefits are provided.

(15)

“Department” means the Maryland Department of Health.

(16)

“Dependent” has the meaning stated in 26 CFR §54.9801-2 with respect to eligibility for coverage under an individual or SHOP QHP because of a relationship to a qualified individual or enrollee.

(17)

“Eligibility determination” means a decision by the Exchange about an applicant’s eligibility to enroll in a QHP or insurance affordability program or terminate a qualified individual’s enrollment in a QHP or insurance affordability program.

(18)

“Enrollee” means a qualified individual, or qualified employee, who is enrolled in a qualified plan through the Individual or SHOP Exchange.

(19)

“Enrollment” means the qualified individual’s coverage in a qualified plan, catastrophic plan, or insurance affordability program through the Exchange.

(20)

“Exchange” has the meaning stated in Insurance Article §31-101(e), Annotated Code of Maryland.

(21)

“Exchange annual training” means the yearly training administered to certified navigators, licensed navigators, application counselors, and authorized producers by the Exchange as part of its training program.

(22)

“Gold coverage level” means the level of coverage described under §1302(d)(1)(C) of the ACA.

(23)

“Grace period” means the period of time during which a carrier is prohibited from terminating an enrollee’s enrollment in a qualified plan, as specified in:

(a)

Insurance Article, §15-1315(c)—(e), Annotated Code of Maryland, if the enrollee is receiving advanced premium tax credits;

(b)

Insurance Article, §15-209, Annotated Code of Maryland, for insurers due to non-payment of premium;

(c)

COMAR 31.10.25.04C, for non-profit health service plans;

(d)

COMAR 31.12.07.05D, for HMOs;

(e)

COMAR 31.12.04.05A, for dental plan organizations;

(f)

COMAR 31.11.10.04I for insurers and non-profit health service plans offering small employer coverage in health benefit plans; or

(g)

COMAR 31.12.07.04I, for HMOs offering small employer coverage in health benefit plans.

(24)

“Health benefit plan” has the meaning stated in Insurance Article, §31-101, Annotated Code of Maryland.

(25)

“HHS” means the federal Department of Health and Human Services.

(26)

“Individual Exchange” has the meaning stated in Insurance Article §31-101(h), Annotated Code of Maryland.

(27)

“Individual Exchange Navigator” has the meaning stated in Insurance Article §31-101(i), Annotated Code of Maryland.

(28)

“Individual Exchange Navigator Certification” has the meaning stated in Insurance Article §31-101(j), Annotated Code of Maryland.

(29)

“Individual Exchange Navigator Entity” has the meaning stated in Insurance Article §31-101(k), Annotated Code of Maryland.

(30)

“Insurance producer” has the meaning stated in Insurance Article §1-101(u), Annotated Code of Maryland.

(31)

“Insurance producer authorization” has the meaning stated in Insurance Article §31-101(m), Annotated Code of Maryland.

(32)

“JAIL MATCH” means the data system containing information about incarcerated individuals within the State.

(33)

“Limited cost sharing plan variation” means the cost-sharing reduction variation of a QHP described in 45 CFR §156.420(b)(2).

(34)

“Managed care program” has the meaning stated in COMAR 10.09.62.01B(100).

(35)

“Maryland Children’s Health Program (MCHP)” has the meaning stated in COMAR 10.09.43.02B.

(36)

“Maryland Insurance Administration” means the insurance administration for the State established under Insurance Article, §2-101, Annotated Code of Maryland.

(37)

“Medicaid” has the meaning stated in COMAR 10.09.24.02B(32).

(38)

“Minimum essential coverage (MEC)” has the meaning stated in 26 USC §5000A(f) and the corresponding regulation under 26 CFR §1.5000A-2(a).

(39)

“Navigator entity” means Individual Exchange Navigator Entity.

(40)

“Open enrollment period” means the annual period during which a qualified individual may enroll in coverage through the Exchange, including the initial open enrollment period as stated in 45 CFR §155.20.

(41)

“Plain language” has the meaning stated in §1311(e)(3)(b) of the Affordable Care Act.

(42)

“Plan variation” means a zero cost sharing plan variation, a limited cost sharing plan variation, or a silver plan variation.

(43)

“Platinum coverage level” means the level of coverage described under §1302(d)(1)(D) of the ACA.

(44)

“Product” has the meaning stated in 45 CFR §154.102.

(45)

“Provider network” has the same meaning as “provider panel” as stated in COMAR 31.10.35.03B(7).

(46)

“Qualified dental plan (QDP)” has the meaning stated in Insurance Article, §31-101, Annotated Code of Maryland.

(47)

“Qualified employee” means an employee who has been determined eligible to enroll in a qualified plan through the SHOP Exchange.

(48)

“Qualified health plan (QHP)” has the meaning stated in Insurance Article, §31-101, Annotated Code of Maryland.

(49)

“Qualified individual” has the meaning stated in Insurance Article, §31-101(s), Annotated Code of Maryland.

(50)

“Qualified plan” has the meaning stated in Insurance Article, §31-101, Annotated Code of Maryland.

(51)

“SHOP Exchange” has the meaning stated in Insurance Article, §31-101, Annotated Code of Maryland.

(52)

“Silver coverage level” means the level of coverage described under §1302(d)(1)(B) of the ACA.

(53)

“Silver plan variation” means any of the cost-sharing reduction plan variations of the standard silver QHP under 45 CFR §156.420(a).

(54)

“Single, streamlined application form” means the eligibility application for Medicaid, MCHP, qualified health plan, stand-alone dental plan, APTC, or CSR through the Exchange.

(55)

“Special enrollment period” means the period during which a qualified individual, dependent, or enrollee, who experiences certain qualifying events may enroll in, or change enrollment in, a QHP through the Exchange outside of the annual open enrollment periods.

(56)

“Stand-alone dental plan (SADP)” means a qualified dental plan that meets the requirements under 45 CFR §155.1065(a).

(57)

“Zero cost sharing plan variation” means the cost-sharing reduction plan variation of a QHP under 45 CFR §156.420(b)(1).

Chapter 02. Individual Exchange Navigator Certification and Training Standards

Regulation .01 Scope.Link Copy Citation

This chapter sets forth the qualifications, training, and certification standards for an individual who applies to receive an Individual Exchange navigator certification and is required under Insurance Article, §31-113(h)(1), Annotated Code of Maryland to hold an Individual Exchange navigator certification to provide the services listed under Insurance Article, §31-113(d)(1), Annotated Code of Maryland.

Regulation .02 Eligibility Requirements.Link Copy Citation

To qualify for an Individual Exchange navigator certification, an applicant shall:

Be of good character and trustworthy;

Be at least 18 years old;

Successfully complete and comply with any ongoing requirements of the training program set forth under regulation .04 of this chapter; and

Comply with any applicable requirements of Maryland Department of Health.

Regulation .03 Application Procedures.Link Copy Citation

In order to obtain an Individual Exchange navigator certification, the applicant shall submit to the Exchange:

(1)

An application on the form provided by the Exchange;

(2)

An attestation that the applicant will notify the Exchange of any changes to information that the applicant provides or to which the applicant attests on the application form within 30 days of such change;

(3)

An application fee if permitted by law and in the manner specified by the Exchange;

(4)

Evidence of the written consent required under COMAR 31.03.12, if applicable; and

(5)

Evidence that the applicant has successfully completed the Individual Exchange navigator certification training program.

The Exchange may not consider an application to be complete until it has received all required materials.

If the application is not completed with all required materials within 45 days after the Exchange receives the signed application form, the Exchange may consider the application withdrawn.

Regulation .04 Training Standards.Link Copy Citation

Scope of Training. The training shall include information on:

(1)

Commercial health insurance;

(2)

The Medicaid and MCHP programs;

(3)

Eligibility, enrollment, renewal and disenrollment;

(4)

Advanced premium tax credits;

(5)

Consumer assistance and protection;

(6)

Quality assurance standards; and

(7)

Ethics.

Conduct.

(1)

The Exchange shall conduct training in geographically diverse locations across the State.

(2)

The training shall be conducted in examination facilities equipped to provide access in accordance with the Americans with Disabilities Act of 1990 as amended under 42 USC §12101, et seq.

Type of Training. The training shall be administered in-person and online.

Examination.

(1)

The training shall include a final examination.

(2)

The examination shall be multiple choice.

(3)

The examination shall be scored and reported in accordance with a passing score established by the Exchange.

(4)

Applicants must successfully pass the examination within 45 calendar days of completing the training described under §A of this regulation.

(5)

Applicants are allowed three attempts to pass the examination in a 12-month period.

(6)

If the applicant does not pass the examination on the third attempt, they must wait 12 months before they are eligible to train and test again.

Training Frequency. The Exchange shall conduct trainings:

(1)

At least monthly during all months; and

(2)

At least weekly for the 3 months immediately preceding the open enrollment period.

Assessment. The Exchange, in consultation with the Maryland Department of Health and with the approval of the Commissioner, shall review, and as appropriate update, the content of the training on a schedule established by the Exchange.

Chapter 03. Individual Exchange Navigator Certification — Renewal, Reinstatement, Deactivation, and Suspension or Revocation of Certification

Regulation .01 Term.Link Copy Citation

An Individual Exchange navigator certification expires 2 years after the date it is issued unless it is renewed.

Regulation .02 Renewal.Link Copy Citation

Notice.

(1)

At least 60 days before the expiration of an Individual Exchange navigator certification, the Exchange shall notify the Individual Exchange navigator, either directly at the address, including email address, on file with the Exchange, or by contacting the navigator entity by whom the Individual Exchange navigator is employed or engaged, of the expiration date of an Individual Exchange navigator certification.

(2)

The notification shall include:

(a)

A renewal application;

(b)

The date by which the Exchange must receive the renewal application for the renewal to be issued before the certification expires; and

(c)

The amount of the renewal fee, if any.

Eligibility for Renewal. An Individual Exchange navigator certification may be renewed for an additional 2-year term if the holder:

(1)

Is otherwise entitled to receive Individual Exchange navigator certification, in accordance with the eligibility requirements set forth in COMAR 14.35.02.02;

(2)

Files a renewal application on the form provided by the Exchange either by mail or electronically before expiration of the certification;

(3)

Pays to the Exchange a renewal fee if permitted by law and in the manner specified by the Exchange; and

(4)

Has completed the Exchange annual training and the continuing education requirements under §C of this regulation.

Continuing Education. A certified Individual Exchange navigator shall complete at least 16 hours of Exchange-approved continuing education per renewal term.

Annual Training.

(1)

The Exchange shall:

(a)

Schedule the Continuing Education Training on an annual basis; and

(b)

Notify certified Individual Exchange navigators of the annual training.

(2)

A certified Individual Exchange navigator shall complete the annual training, including any examination, within 60 days before the open enrollment period during each year of the certification term, including any renewal term.

Regulation .03 Reinstatement.Link Copy Citation

In order to obtain a reinstatement of an Individual Exchange navigator certification, the applicant shall submit to the Exchange an application as required under COMAR 14.35.02.03.

Regulation .04 Inactive Certification.Link Copy Citation

An Individual Exchange navigator shall provide evidence satisfactory to the Exchange of employment or engagement by a navigator entity before the navigator may become certified.

The Exchange may deactivate an individual’s Individual Exchange navigator certification whenever the:

(1)

Individual fails to complete the annual training;

(2)

Individual has not provided evidence satisfactory to the Exchange of employment or engagement by a navigator entity, as set forth under §A of this regulation; or

(3)

The Exchange is informed, either by the individual or a navigator entity, that the individual is not employed or engaged by the navigator entity.

If certification is deactivated due to reasons listed under §B(2) or (3) of this regulation, the Exchange may waive the fees listed under Regulation .02B(3) of this chapter.

Regulation .05 Suspension or Revocation.Link Copy Citation

The Commissioner may suspend or revoke an Individual Exchange navigator certification for the reasons listed under Insurance Article, §31-113(l)(1), Annotated Code of Maryland.

Chapter 04. Insurance Producer Authorization to Sell Qualified Plans in the SHOP Exchange and Individual Exchange

Regulation .01 Scope.Link Copy Citation

This chapter sets forth the qualifications, training, and authorization standards for an individual who applies to receive a Small Business Health Options (SHOP) insurance producer authorization or an Individual Exchange insurance producer authorization and is required under Insurance Article, §§31-112(g)(2) and 31-113(n)(2), Annotated Code of Maryland, to hold such an authorization to sell qualified plans within the SHOP Exchange or Individual Exchange.

Regulation .02 Eligibility Requirements.Link Copy Citation

To be eligible to apply for initial insurance producer authorization, an applicant shall:

Be licensed by the Maryland Insurance Commissioner as an insurance producer authorized to sell health insurance; and

Successfully complete and comply with any ongoing requirements of the training programs set forth under Regulation .04 of this chapter.

Regulation .03 Application Procedures.Link Copy Citation

In order to obtain a SHOP Exchange insurance producer authorization or Individual Exchange insurance producer authorization, the applicant shall submit to the Exchange:

(1)

An application on the form provided by the Exchange;

(2)

An attestation that the applicant will notify the Exchange of any changes to information the applicant provides or to which the applicant attests on the application form within 30 days of such change;

(3)

An application fee if permitted by law and in the manner specified by the Exchange;

(4)

Evidence that the applicant is licensed by the Maryland Insurance Commissioner as an insurance producer authorized to sell health insurance;

(5)

Evidence of the written consent required under COMAR 31.03.12, if applicable; and

(6)

Evidence that the applicant has successfully completed the:

(a)

SHOP Exchange insurance producer authorization training if the applicant is applying for a SHOP Exchange insurance producer authorization; or

(b)

Individual Exchange Producer Authorization training if the applicant is applying for an Individual Exchange insurance producer authorization.

The Exchange may not consider an application to be complete until it has received all required materials.

If the application is not completed with all required materials within 45 days after the Exchange receives the signed application form, the Exchange may consider the application withdrawn.

Regulation .04 Training.Link Copy Citation

An applicant for the SHOP Exchange insurance producer authorization shall complete the Exchange-approved SHOP insurance producer authorization training.

An applicant for the Individual Exchange insurance producer authorization shall complete the Commissioner-approved Individual Exchange insurance producer authorization training.

The Exchange shall review, and as appropriate update, the content of the SHOP insurance producer authorization training program on a schedule established by the Exchange.

The Exchange, with the approval of the Commissioner, shall review, and as appropriate update, the content of the Individual Exchange insurance producer authorization training program at least every 2 years.

An applicant for Individual Exchange or SHOP insurance producer authorization shall meet the examination requirements specified under COMAR 14.35.02.04D.

Chapter 05. Insurance Producer Authorization — Renewal, Reinstatement, and Suspension or Revocation of Authorization

Regulation .01 Term.Link Copy Citation

An insurance producer authorization expires 2 years after the date it is issued unless it is renewed.

Regulation .02 Renewal.Link Copy Citation

Notice.

(1)

At least 60 days before the expiration of an insurance producer authorization, the Exchange shall notify the authorized insurance producer of the expiration of the authorization.

(2)

The notification shall include:

(a)

A renewal application;

(b)

The date by which the Exchange must receive the renewal application for the renewal to be issued before the authorization expires; and

(c)

The amount of the renewal fee, if any.

Eligibility for Renewal. An insurance producer authorization may be renewed for an additional 2-year term if the holder:

(1)

Is otherwise entitled to receive insurance producer authorization, in accordance with the eligibility requirements set forth in COMAR 14.35.04.02;

(2)

Files a renewal application on the form provided by the Exchange before the expiration of the authorization;

(3)

Pays to the Exchange a renewal fee if permitted by law and in the manner specified by the Exchange;

(4)

Completes the annual training requirements set forth in COMAR 14.35.04.04; and

(5)

Is not denied by the Exchange for reasons set forth under §E of this regulation.

Exchange Annual Training.

(1)

The Exchange shall:

(a)

Schedule the Exchange Annual Training; and

(b)

Notify authorized insurance producers of the annual training.

(2)

Authorized insurance producers shall complete the annual training, including any examination, within 60 days before the open enrollment period.

Timely Receipt of Application:

(1)

Before the date of expiration of the authorization, a holder of an insurance producer authorization shall complete and return to the Exchange a renewal application and a renewal fee according to the renewal instructions.

(2)

A holder of an expired insurance producer authorization may not sell qualified plans in the SHOP Exchange or Individual Exchange.

Denial.

(1)

The Exchange may deny a renewal application if the insurance producer has:

(a)

Committed any act described in Insurance Article, §31-113(l)(1), Annotated Code of Maryland; or

(b)

Had any professional license or certification suspended or revoked for a fraudulent or dishonest practice.

(2)

Denial of a renewal application is subject to the contested case hearing provisions of State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland.

Regulation .03 Reinstatement.Link Copy Citation

For up to 1 year after the expiration date, an individual whose insurance producer authorization has expired may apply to reinstate the expired authorization by:

(1)

Filing a reinstatement application, either by mail or electronically, on the form approved by the Exchange;

(2)

Paying to the Exchange the renewal fee if permitted by law and in the manner specified by the Exchange;

(3)

Paying to the Exchange a reinstatement fee if permitted by law and in the manner specified by the Exchange; and

(4)

Submitting evidence to the Exchange that the individual has successfully completed the Exchange annual training and the continuing education requirements under Regulation .02C of this chapter.

An individual who does not file for reinstatement within 1 year after the expiration date of the insurance producer authorization shall apply for an authorization under the application procedures set forth in COMAR 14.35.04.03.

Regulation .04 Suspension or Revocation.Link Copy Citation

The Exchange may suspend or revoke an insurance producer authorization for a licensed producer authorized to sell qualified plans in the SHOP Exchange as set forth under Insurance Article, §31-112(f)(3)(i), Annotated Code of Maryland.

The Exchange may suspend or revoke an insurance producer authorization for a licensed producer authorized to sell qualified plans in the Individual Exchange as set forth under Insurance Article, §31-113(m)(3)(i), Annotated Code of Maryland.

Chapter 06. Exchange Consumer Services Center

Regulation .01 Exchange Call Center.Link Copy Citation

The Exchange shall:

Maintain a consumer services call center at least during normal business hours;

Operate its consumer services call center as a triage device to handle or properly refer consumers' questions or complaints; and

Provide a consumer with information about how to use the consumer services call center to obtain information and assistance when appropriate.

Chapter 07. Eligibility Standards for Enrollment in a Qualified Health Plan, Eligibility Standards for APTC and CSR, and Eligibility Standards for Enrollment in a Catastrophic Qualified Health Plan in the Individual Exchange

Regulation .01 Scope.Link Copy Citation

This chapter sets forth the eligibility standards for enrollment in a qualified health plan and qualified health plans with advance payments of the premium tax credit and cost-sharing reductions in the Individual Exchange. This chapter does not address the verification of eligibility or redeterminations of eligibility for enrollment in the Individual Exchange or eligibility for enrollment in the SHOP Exchange. This chapter does not address eligibility and enrollment in qualified dental plans or qualified vision plans.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

“Applicant” means an individual who submits an application through the Individual Exchange for the individual and the individual’s tax household, and is seeking eligibility for:

(a)

Enrollment in a QHP through the Individual Exchange; or

(b)

Enrollment in an insurance affordability program through the Individual Exchange.

(2)

“COBRA” means the Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub. L. 99-272).

(3)

“CSR plan for up to 150 percent FPL” means a QHP available through the Individual Exchange with an actuarial value of 94 percent plus or minus the de minimis variation for a silver plan variation.

(4)

“CSR plan for 151—200 percent FPL” means a QHP available through the Individual Exchange with an actuarial value of 87 percent plus or minus the de minimis variation for a silver plan variation.

(5)

“CSR plan for 201—250 percent FPL” means a QHP available through the Individual Exchange with an actuarial value of 73 percent plus or minus the de minimis variation for a silver plan variation.

(6)

“Dependent,” for the purposes of Regulations .12—.19 of this chapter, has the meaning stated in 26 CFR §54.9801-2 with respect to eligibility for coverage under an individual QHP because of a relationship to a qualified individual or enrollee.

(7)

“Employer group health insurance coverage” means health coverage offered by an employer to an employee and the employee’s dependents, if eligible, under:

(a)

Government health coverage, such as the Federal Employees Health Benefit program;

(b)

Health coverage offered in the small or large group market by an employer within a state; or

(c)

Grandfathered health coverage offered by an employer in a group market.

(8)

“Federal poverty level (FPL)” means the most recently published federal poverty level guidelines, updated periodically in the Federal Register by the Secretary of HHS as set forth in 42 U.S.C. §9902(2), as of the first day of the open enrollment period for QHPs offered through the Individual Exchange for a calendar year.

(9)

Household income” has the meaning stated in §36B(d)(2) of the Internal Revenue Code.

(10)

“Indian” means an individual who is a member of an Indian tribe, band, nation, or other organized group or community, including any Alaska Native village, or regional or village corporation as defined in or established under the Alaska Native Claims Settlement Act (85 Stat. 688), which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.

(11)

“Institution” means:

(a)

A medical institution under COMAR 10.09.24.02—.37; or

(b)

A public institution under COMAR 10.09.24.02—.46.

(12)

“Insurance affordability program” means a program that is one of the following:

(a)

The Maryland State Medicaid Program;

(b)

The Maryland Children’s Health Insurance Program (CHIP), including the Maryland Children’s Health Program (MCHP) Premium;

(c)

A program that makes available to qualified individuals coverage in a QHP through the Individual Exchange with APTC credit under §1.36B(2)(c) of the Internal Revenue Code;

(d)

A program that makes available coverage in a QHP through the Individual Exchange with CSR under §1402 of the ACA; and

(e)

The State-Based Young Adult Health Insurance Subsidies Program established under Insurance Article, §31-122, Annotated Code of Maryland.

(13)

“Non-applicant” means an individual who is not seeking eligibility for enrollment in a QHP or an insurance affordability program through the Individual Exchange.

(14)

“Qualifying eligible employer-sponsored plan” means a health benefit plan that meets the requirements set forth in 26 CFR §1.36B-2(c)(2)(i).

(15)

“Rescission” means a cancellation or discontinuance of coverage that has retroactive effect.

(16)

“Tax filer” means an individual or married couple who indicates that the tax filer expects:

(a)

To file an income tax return for the benefit year, as set forth in 26 U.S.C. §§6011, 6012, and implementing regulations;

(b)

If married, as set forth in 26 CFR §1.7703-1, to file a joint tax return for the benefit year, except if the spouse is a victim of domestic violence or spousal abandonment;

(c)

To not be claimed as a tax dependent by any other taxpayer for the benefit year; and

(d)

To claim a personal exemption deduction set forth in §151 of the Internal Revenue Code on the tax filer’s return for one or more applicants, even if the tax filer is not an applicant.

Regulation .03 Applying for Coverage Through the Individual Exchange.Link Copy Citation

Individuals may apply to enroll in a QHP or an insurance affordability program through the Individual Exchange using the single, streamlined application form approved by the Individual Exchange.

An individual may submit the application:

(1)

By telephone;

(2)

On the Individual Exchange’s internet website;

(3)

Using in-person assistance, including with the provision of reasonable accommodations; or

(4)

By mail.

An applicant shall provide the following information on the application:

(1)

The applicant’s and applicable dependents’ Social Security numbers, provided that the applicant and applicable dependents have Social Security numbers;

(2)

An authorization for the Exchange to verify attested information through electronic means;

(3)

An election indicating whether the applicant is seeking an eligibility determination for enrollment in a QHP or insurance affordability program;

(4)

If the applicant is applying for enrollment in a QHP, sufficient information to determine eligibility for enrollment in a QHP;

(5)

If the applicant is applying for enrollment in an insurance affordability program, sufficient information to determine eligibility for enrollment in such insurance affordability program;

(6)

If the applicant is applying for enrollment in an insurance affordability program as defined in Regulation .02B and the applicant files for an income tax return as a married couple, the applicant shall complete an attestation that the applicant intends to file a joint income tax return for the benefit year in which the individual is seeking coverage, except:

(a)

If a spouse is the victim of domestic violence or spousal abandonment, the attestation may provide that the applicant intends to file a single income tax return for the benefit year in which the individual is seeking coverage; or

(b)

If the individual in a married couple qualifies to file as head of household, the attestation may provide that the applicant intends to file a single income tax return as head of household for the benefit year in which the individual is seeking coverage; and

(7)

The applicant’s signature, including either an electronic or telephonic signature, under penalties of perjury.

Non-applicant.

(1)

A non-applicant who applies for insurance affordability programs on behalf of a member in the non-applicant’s tax filing household shall provide the following information on the application:

(a)

The non-applicant’s name; and

(b)

The non-applicant’s Social Security number, if the applicant attests that the tax filer:

(i)

Has a Social Security number; and

(ii)

Filed a tax return for the year for which tax data would be used to verify the applicant’s household income and family size.

(2)

A non-applicant is required to provide the following information on the application if the only members of the individual’s household seeking coverage are younger than 18 years old and are not emancipated minors:

(a)

The non-applicant’s name; and

(b)

The non-applicant’s address.

(3)

Non-applicants are not required to provide information about the non-applicant’s citizenship, status as a national, or immigration status.

An individual who applies for an insurance affordability program shall receive an eligibility determination for all of the insurance affordability programs.

An individual may submit an application to the Individual Exchange and receive an eligibility determination at any time during the year.

Incomplete Applications.

(1)

If an individual submits an incomplete application, the Individual Exchange shall send the individual a notice under Regulation .04D of this chapter.

(2)

The individual shall have 90 days to complete the application and receive an eligibility determination from the date the notice is sent to the individual under Regulation .04D of this chapter.

(3)

If an individual does not complete and submit an application within the 90 days under §G(2) of this regulation, the Individual Exchange shall close the application and the individual shall begin a new application.

An individual shall complete and submit an application to enroll in coverage through the Exchange.

Regulation .04 Notice Requirements.Link Copy Citation

The Individual Exchange shall provide timely written notice to an applicant of any eligibility determination made under this chapter as set forth in 45 CFR §155.230 and a notification of the right to request a fair hearing as set forth in COMAR 14.35.11.04.

If an employee enrolls in a QHP with APTC or CSR, the Individual Exchange shall notify the employee’s employer at the employer’s address provided by the employee to the Individual Exchange that the employee has been determined eligible for APTC or CSR.

The notice under §B of this regulation shall:

(1)

Identify the employee by including:

(a)

The employee’s name;

(b)

The employee’s date of birth;

(c)

The last four digits of the employee’s Social Security number, if available; and

(d)

The employee’s Individual Exchange identification number;

(2)

Indicate that the employee has been determined eligible for APTC or CSR and has enrolled in a QHP;

(3)

Indicate that if the employer has 50 or more full-time employees, the employer may be liable for the shared responsibility payment assessment set forth in §4980H of the Internal Revenue Code; and

(4)

Notify the employer of the employer’s right to appeal the determination to HHS.

The Exchange shall send a notice to an applicant who submits an application containing insufficient information for the Exchange to conduct an eligibility determination, which shall:

(1)

Indicate that the information necessary to complete an eligibility determination is missing;

(2)

Specify the missing information;

(3)

Provide instructions on how to provide the missing information to the Individual Exchange; and

(4)

Specify that the applicant shall have 90 days to provide the missing information to the Individual Exchange beginning by the date of the notice.

If the applicant or enrollee has designated an authorized representative under Regulation .20 of this chapter, the Individual Exchange shall provide:

(1)

Information regarding the powers and duties of authorized representatives to both the applicant or enrollee and to the authorized representative; and

(2)

Notices to the applicant or enrollee and to the authorized representative.

The Individual Exchange shall provide written notice electronically to the individual if:

(1)

The individual elects to receive notices electronically;

(2)

The individual is mailed confirmation of the individual’s election to receive notices electronically;

(3)

The individual is informed of the right to change the election;

(4)

The Individual Exchange posts notices in the individual’s online Individual Exchange account within 1 business day of generation of the electronic notice; and

(5)

Within 1 business day of generating the electronic notice, the Individual Exchange alerts the individual, via email to the individual’s verified email address, to the existence of the electronic notice in the individual’s online Individual Exchange account.

If the electronic communication under §F(5) of this regulation fails to be sent to the individual, the Individual Exchange shall mail a written notice of the failed electronic communication to the individual’s mailing address.

An individual may request a written copy of any electronic notice the individual receives from the Individual Exchange.

Regulation .05 Eligibility Requirements for Enrollment in a Qualified Health Plan Through the Individual Exchange.Link Copy Citation

An applicant shall be determined eligible for enrollment in a QHP through the Individual Exchange if the applicant is:

(1)

A citizen or national of the United States, a non-citizen who is lawfully present in the United States, and reasonably expected to be a citizen, national, or a non-citizen who is lawfully present for the entire period for which enrollment is sought;

(2)

A resident of the Individual Exchange service area; and

(3)

Not incarcerated, other than incarceration pending the disposition of charges.

Eligibility under this regulation is contingent upon verification of the applicant’s attestation that the applicant meets the criteria stated in §A(1) of this regulation, or upon receipt of the applicant’s attestation that the applicant meets the criteria stated in §A(2) and (3) of this regulation.

For the purpose of determining eligibility for enrollment in a QHP under §A(1) of this regulation, “lawfully present” means a non-citizen individual as defined in 45 CFR §152.2.

Regulation .06 General Eligibility Requirements — Citizenship and Immigration Status.Link Copy Citation

For the purpose of determining eligibility for enrollment in a QHP under Regulation .05A(1) and (2) of this chapter, an individual shall be considered a citizen or national of the United States if the individual is:

A citizen of the United States, including:

(1)

An individual who was born in:

(a)

One of the 50 states;

(b)

The District of Columbia;

(c)

Puerto Rico;

(d)

Guam;

(e)

The Northern Mariana Islands; or

(f)

The U.S. Virgin Islands; or

(2)

A child born outside of the United States if:

(a)

The federal requirements, including the requirements in the Child Citizenship Act of 2000 (Public Law 106-395), are met for the child to automatically acquire United States citizenship upon the child's lawful admission to the United States for permanent residence;

(b)

At least one of the child's natural or adoptive parents or stepparents is a United States citizen by birth or naturalization;

(c)

The child is younger than 18 years old;

(d)

The child resides in the United States in the legal and physical custody of the citizen or naturalized parent; and

(e)

The child is a lawful permanent resident of the United States;

A naturalized United States citizen; or

A national from American Samoa or Swain's Island.

Regulation .07 General Eligibility Requirements — Residency in Individual Exchange Service Area.Link Copy Citation

For the purpose of determining eligibility for enrollment in a QHP under Regulation .05(A)(2) of this chapter, an individual shall be considered a resident of the Exchange service area if:

(1)

An individual is 21 years old or older, is not living in an institution, is capable of indicating intent, and is not receiving an optional State supplementary payment and the individual lives in the Individual Exchange service area, including without a fixed address; or

(2)

An individual is younger than 21 years old, is not living in an institution, is not eligible for Medicaid based on receipt of assistance under Title IV-E of the Social Security Act, is not emancipated, is not receiving an optional State supplementary payment, and the individual either:

(a)

Resides in the Exchange service area, including without a fixed address; or

(b)

Resides with a parent or caretaker who resides in the service area of the Individual Exchange under §A(1) of this regulation.

For individuals not described in §A of this regulation, an individual shall be considered a resident of the Individual Exchange service area if the individual meets the State residency requirements set forth in COMAR 10.09.24.05-3.

If members of the tax household are not residents of the same Individual Exchange service area, the tax household may indicate any Individual Exchange service area for which one of the tax filers meets the regulation as the tax household’s residency.

If both spouses in a tax household enroll in a QHP through the same Individual Exchange, a tax dependent may only enroll in a QHP through the Individual Exchange, or through a different health benefit exchange for which the dependent meets the residency standard.

The Individual Exchange may not deny or terminate an individual's eligibility for enrollment in a QHP through the Individual Exchange if the individual meets the residency standard under this regulation but for a temporary absence from the service area of the Individual Exchange and the individual intends to return when the purpose of the absence has been accomplished.

The service area of the Individual Exchange is Maryland.

Regulation .08 Eligibility Requirements for Advance Payments of the Premium Tax Credit.Link Copy Citation

A tax filer shall be determined eligible for APTC if:

(1)

The tax filer attests to a household income, as defined in 26 CFR §1.36B-1(e), greater than or equal to 100 percent but not more than 400 percent of the FPL for the benefit year for which coverage is requested; and

(2)

One or more applicants for whom the tax filer attests to claiming a personal exemption deduction on the applicant’s federal tax return for the benefit year:

(a)

Meet the requirements for eligibility for enrollment in a QHP through the Individual Exchange, as specified in Regulation .05 of this chapter; and

(b)

Are not eligible for minimum essential coverage, with the exception of coverage in the individual market as set forth in 26 CFR §1.36B-2(a)(2) and (c).

A non-citizen tax filer who is lawfully present and ineligible for Medicaid or MCHP by reason of immigration status, and is not otherwise eligible for APTC, shall be eligible for APTC if:

(1)

The tax filer meets the requirements specified in §A(2) of this regulation;

(2)

The tax filer attests to household income of less than 100 percent of the FPL for the benefit year for which coverage is requested; and

(3)

One or more applicants for whom the tax filer attests to claiming a personal exemption deduction on the tax filer’s return for the benefit year is a non-citizen who is lawfully present and ineligible for Medicaid or MCHP by reason of immigration status.

A tax filer is eligible for APTC for another qualified individual only if one or more qualified individuals, for whom the tax filer attests that the tax filer expects to claim a personal exemption deduction for the benefit year, including the tax filer and the tax filer’s spouse, is enrolled in a QHP that is not a catastrophic plan through the Individual Exchange.

If one or more APTC amounts are to be made on behalf of a tax filer, or two tax filers covered by the same plan or plans, and individuals in the tax filers’ tax households are enrolled in more than one QHP, or stand-alone dental plan, then the APTC amounts shall be allocated as follows:

(1)

That portion of the APTC that is less than or equal to the aggregate adjusted monthly premiums, as set forth in 26 CFR §1.36B-3(e), and that is properly allocated to essential health benefits shall be allocated among the QHPs according to the premium level appropriate for each individual’s age-rating band premium; and

(2)

Any remaining APTC may be allocated to the essential health benefit portion of any stand-alone dental plans.

For 2024 and prior years, a tax filer may not be eligible for APTC if:

(1)

HHS notifies the Individual Exchange that APTC was made on behalf of the tax filer, or either spouse if the tax filer is a married couple, for a year for which tax data would be utilized for verification of household income and family size set forth in 45 CFR §155.320(c)(1)(i); and

(2)

The tax filer or spouse did not file a federal income tax return and reconcile the APTC received for that year, or previous years.

Beginning 2025, a tax filer may not be eligible for APTC if:

(1)

HHS notifies the Individual Exchange that APTC was made on behalf of the tax filer, or either spouse if the tax filer is a married couple, for 2 consecutive years for which tax data would be utilized for verification of household income and family size as set forth in 45 CFR §155.320(c)(1)(i); and

(2)

The tax filer or spouse did not file a federal income tax return and reconcile the APTC received for that year and for the previous year.

APTC shall be calculated in accordance 26 CFR §1.36B-3.

To receive the APTC, the tax filer shall attest that:

(1)

No other tax filer will claim the tax filer as a tax dependent for the benefit year; and

(2)

The tax filer will claim a personal exemption deduction on the income tax return for the applicants identified as members of the tax filer’s family, including the tax filer, who:

(a)

Meet the requirements for eligibility for enrollment in a QHP through the Individual Exchange, under Regulation .05 of this chapter; and

(b)

Are not eligible for minimum essential coverage elsewhere.

An enrollee may accept less than the full amount of the APTC for which the enrollee is determined eligible.

Effective Dates for Changes in Eligibility for APTC for Enrollees.

(1)

Except as otherwise specified under this regulation, changes in eligibility for APTC determined by the Individual Exchange are effective the first day of the month following the date on which the determination is made.

(2)

When an enrollee is determined newly eligible for Medicaid or MCHP, the enrollee shall be ineligible for APTC beginning the first of the month after the enrollee is determined newly eligible for Medicaid or MCHP.

(3)

When an applicant or enrollee is eligible for a special enrollment period under Regulations .12—.19 of this chapter, the applicant or enrollee shall be in accordance with the applicable effective date specified for each special enrollment period under Regulations .12—.19 of this chapter.

(4)

When an enrollee’s enrollment is terminated by the enrollee as set forth in 45 CFR §155.430(b)(1) or terminated by the Exchange under 45 CFR §155.430(b)(2)(i)—(vii), the applicant or enrollee shall be in accordance with the applicable effective date of the termination set forth in 45 CFR §155.430(d).

Eligibility under this regulation is contingent upon verification of the applicant’s attestation that the applicant meets the criteria stated in this regulation.

Regulation .09 Eligibility Requirements for Cost — Sharing Reductions.Link Copy Citation

An applicant shall be determined eligible for cost-sharing reductions if the applicant:

(1)

Meets the requirements for eligibility for enrollment in a QHP through the Exchange under Regulation .05 of this chapter;

(2)

Meets the requirements for APTC under Regulation .08 of this chapter; and

(3)

Except as provided under §E of this regulation, attests to household income that does not exceed 250 percent of the FPL for the benefit year for which coverage is requested.

An applicant is eligible for:

(1)

A CSR plan for up to 150 percent FPL for an individual who attests to household income greater than or equal to 100 percent of the FPL and less than or equal to 150 percent of the FPL for the benefit year for which coverage is requested, or, for an individual who is eligible for advance payments of the premium tax credit under Regulation .07B of this chapter, a household income less than 100 percent of the FPL for the benefit year for which coverage is requested;

(2)

A CSR plan for 151—200 percent FPL for an individual who attests to household income greater than 150 percent of the FPL and less than or equal to 200 percent of the FPL for the benefit year for which coverage is requested;

(3)

A CSR plan for 201—250 percent FPL for an individual who attests to household income greater than 200 percent of the FPL and less than or equal to 250 percent of the FPL for the benefit year for which coverage is requested; or

(4)

Except as provided under §E of this regulation, any coverage level for an individual who attests to household income greater than 250 percent for the FPL for the benefit year for which coverage is requested.

To the extent that an enrollment in a QHP under a single policy covers two or more individuals who, if the individuals were to enroll in separate individual policies, would be eligible for different CSR plan variations, the individuals under the policy are collectively eligible only for the category of eligibility listed below for which all the individuals covered by the policy would be eligible:

(1)

Individuals not eligible for changes to cost sharing;

(2)

Individuals described in §E(2) of this regulation;

(3)

Individuals described in §B(3) of this regulation;

(4)

Individuals described in §B(2) of this regulation;

(5)

Individuals described in §B(1) of this regulation; and

(6)

Individuals described in §E(1) of this regulation.

Except as set forth in §E of this regulation, to receive cost-sharing reductions, an applicant shall enroll in a silver-plan variation of a QHP.

Special Cost-Sharing Rules for Indians.

(1)

An applicant who is an Indian is eligible for the zero cost sharing plan variation of a QHP if the applicant:

(a)

Meets the requirements for eligibility for enrollment in a QHP through the Individual Exchange pursuant to Regulation .05 of this chapter;

(b)

Meets the requirements for APTC pursuant to Regulation .08 of this chapter; and

(c)

Attests to household income, set forth in 26 CFR §1.36B-1(e) that does not exceed 300 percent of the FPL for the benefit year for which coverage is requested.

(2)

An applicant who is an Indian and is enrolled in a QHP shall owe no cost-sharing under the plan for items or services furnished directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under contract health services.

Changes in enrollment in a plan with a CSR under this regulation are effective based on the effective dates under Regulation .08I of this chapter.

Eligibility under this regulation is contingent upon verification of the applicant’s attestation that the applicant meets the criteria stated in this regulation.

Regulation .10 Eligibility Requirements for Enrollment in a Catastrophic Plan.Link Copy Citation

An applicant shall be determined eligible for enrollment through the Individual Exchange in a catastrophic plan if the applicant has met the requirements for eligibility for enrollment in a QHP through the Individual Exchange under Regulation .05 of this chapter and either:

(1)

Is younger than 30 years old before the beginning of the plan year; or

(2)

Has a certification in effect for any plan year that the applicant is exempt from the requirement to maintain minimum essential coverage set forth in §5000A of the Internal Revenue Code by reason of:

(a)

Section 5000A(e)(1) of the Internal Revenue Code, regarding individuals without affordable coverage; or

(b)

Section 5000A(e)(5) of the Internal Revenue Code, regarding individuals with hardships.

The certification described in §A(2) of this regulation may be provided by the U.S. Department of Health and Human Services or the Individual Exchange.

Changes in enrollment in a catastrophic plan under this regulation are effective based on the effective dates under Regulation .08I of this chapter.

Eligibility under this regulation is contingent upon verification of the applicant’s attestation that the applicant meets the criteria stated in this regulation.

Regulation .11 Enrollment in a QHP or Insurance Affordability Program Through the Individual Exchange.Link Copy Citation

A qualified individual may enroll in a QHP or an insurance affordability program under Regulation .02B(12)(c) and .02B(12)(d) of this chapter, through the Individual Exchange only during:

(1)

The annual open enrollment period of the Individual Exchange, or

(2)

A special enrollment period for which the Individual Exchange has determined that the qualified individual is eligible.

The annual open enrollment period for the Individual Exchange shall be:

(1)

For the benefit year beginning on January 1, 2019, November 1, 2018 through December 15, 2018;

(2)

For the benefit years beginning on January 1, 2020 and on January 1, 2021, November 1 through December 15 of the calendar year preceding the benefit year; and

(3)

For the benefit years beginning on January 1, 2022 and after, November 1 of the calendar year preceding the benefit year through January 15 of the benefit year.

The Individual Exchange may modify or extend the annual open enrollment period each year with the approval of the Board of Trustees and consistent with 45 CFR §155.410.

Coverage selected during an open enrollment period shall:

(1)

For the benefit year beginning on January 1, 2019, be effective on:

(a)

January 1, 2019, for QHP selections received by the Individual Exchange on or before December 15, 2018; and

(b)

January 1, 2019, or later as determined by the Board of Trustees, for QHP selections received by the Individual Exchange on or after December 16, 2018 and on or before December 31, 2018 if the Board of Trustees modifies or extends the annual open enrollment period under Regulation .11C of this chapter; and

(2)

For the benefit year beginning on January 1, 2020 and after, be effective on:

(a)

January 1 for QHP selections received by the Individual Exchange on or before December 15 of the calendar year preceding the benefit year;

(b)

January 1 or later, for QHP selections received by the Individual Exchange on or after December 16 and on or before December 31 of the calendar year preceding the benefit year if the Board of Trustees modifies or extends the annual open enrollment period under Regulation .11C of this chapter; and

(c)

February 1 for QHP selections received by the Individual Exchange on or after January 1 or before January 15 of the benefit year.

If an individual enrolls in a QHP, the Individual Exchange shall promptly and without undue delay transmit to the carrier of the QHP the information necessary to enable the QHP’s carrier to enroll the qualified individual in the QHP selected by the qualified individual, including:

(1)

The qualified individual’s selected QHP;

(2)

The qualified individual’s eligibility or change in eligibility for APTC or a CSR plan, if applicable;

(3)

Whether the carrier should apply, remove, or change the total amount of the qualified individual’s APTC, if applicable;

(4)

The dollar amount of the APTC, if any;

(5)

The advance payment amount of the CSR plan, if any; and

(6)

The effective date of the QHP enrollment.

Payment of First Month’s Premium.

(1)

A qualified individual shall pay the first month's premium to the carrier of the QHP to effectuate enrollment in the QHP when the individual has:

(a)

Enrolled in a QHP after coverage from a previous enrollment in a QHP the individual had was terminated;

(b)

Enrolled for the first time in a QHP in the Individual Exchange; or

(c)

Enrolled in a QHP offered by a different carrier of the same holding company in the Individual Exchange.

(2)

The first month’s premium payment to effectuate prospective coverage for QHP selections made during an annual open enrollment period or during a special enrollment period under Regulations .13E(4), .18D(1)—(2) and .19I of this chapter shall be due on a uniformly applied date specified by the authorized carrier of the QHP that is no earlier than the coverage effective date but no later than 30 calendar days from the coverage effective date.

(3)

The first month’s premium payment to effectuate prospective coverage for QHP selections made during a special enrollment period under Regulations .12F, .13E(1) and (3), .14F, .15G, .16F, .17F, .18D(3), and .19A of this chapter shall be due on a date specified by the authorized carrier of the QHP and uniformly applied that is no earlier than the coverage effective date or no later than 30 calendar days from the date the carrier receives the enrollment transaction from the Exchange or the coverage effective date, whichever is later.

(4)

Payment to effectuate retroactive coverage shall include the premium due for all months of retroactive coverage and shall also include the full premium amount of the first prospective month of coverage.

(5)

Payment to effectuate retroactive coverage for QHP selections made during a special enrollment period shall be due on a uniformly applied date specified by the authorized carrier that is no earlier than the coverage effective date and no later than 30 calendar days from the date the carrier receives the enrollment transaction from the Individual Exchange or the coverage effective date, whichever is later.

(6)

Effective January 1, 2020, payment to effectuate retroactive coverage for QHP selections made during a special enrollment period under Regulations .13E(2), .14F, .15G, .16F, and .17F of this chapter shall be due on the first day of the first full prospective coverage month.

(7)

An authorized carrier may choose to extend the premium due date under §F of this regulation if the carrier does so in a uniform and consistent manner for all similarly situated applicants.

Premium Payment Threshold Policy.

(1)

An authorized carrier may establish a premium payment threshold policy.

(2)

Under the premium payment threshold policy the authorized carrier may consider the individual or enrollee to have paid all amounts due if the enrollee pays an amount sufficient of the total premium owed equal to or greater than a level determined by the carrier.

(3)

If an authorized carrier establishes a premium payment threshold policy, the authorized carrier shall:

(a)

Determine a premium payment level that is reasonable; and

(b)

Apply the premium payment level and the premium payment threshold policy in a uniform manner to all qualified individuals and enrollees.

(4)

If a qualified individual satisfies the authorized carrier’s premium payment threshold policy, the authorized carrier shall effectuate an enrollment based on payment of the initial premium payment under §F of this regulation;

(5)

If an enrollee satisfies the authorized carrier’s premium payment threshold policy, the authorized carrier may not:

(a)

Trigger a grace period for non-payment of premium set forth in:

(i)

Insurance Article, §15-1315(c)—(e), Annotated Code of Maryland, if the enrollee is receiving APTC; or

(ii)

Insurance Article, §15-209, Annotated Code of Maryland (for insurers), COMAR 31.10.25.04C (for nonprofit health services plans), or COMAR 31.12.07.05D (for HMOs) if the enrollee is not receiving APTC; or

(b)

Terminate the enrollment for non-payment of premium under 45 CFR §155.430(b)(2)(ii).

An authorized carrier shall accept and process an enrollment for a qualified individual that does not include a Social Security number.

The Individual Exchange shall maintain records of all enrollments through the Individual Exchange.

Regulation .12 Special Enrollment Periods — Loss of Minimum Essential Coverage or Termination of Other Specified Coverage Through the Individual Exchange.Link Copy Citation

A qualified individual and, when specified in this regulation, an enrollee, a qualified individual’s dependent, or an enrollee’s dependent are eligible for a special enrollment period for loss of minimum essential coverage or other specified coverage if:

(1)

The qualified individual or the qualified individual’s dependent loses minimum essential coverage;

(2)

A qualified individual or a qualified individual’s dependent was enrolled in coverage through a non-calendar year group health plan, individual health insurance coverage, or qualified small employer health reimbursement arrangement (as defined in §9831(d)(2) of the Internal Revenue Code) and the policy or plan year ends in the middle of the calendar year, even if the qualified individual or the qualified individual’s dependent has the option to renew the coverage;

(3)

A qualified individual or the qualified individual’s dependent loses pregnancy-related coverage described in COMAR 10.09.24.03A(2) and 45 CFR §155.420(d)(1)(iii) or loses access to health care services through coverage provided to a pregnant women’s unborn child based on the definition of a child in 42 CFR §457.10; or

(4)

A qualified individual or the qualified individual’s dependent loses the medically needy coverage under COMAR 10.09.24.03E.

(1)

The qualified individual or the qualified individual’s dependent loses eligibility for qualifying eligible employer-sponsored minimum coverage that is not COBRA continuation coverage for reasons including:

(a)

Legal separation;

(b)

Divorce;

(c)

Cessation of dependent status;

(d)

Death of an employee;

(e)

Termination of employment;

(f)

Reduction in the number of hours of employment;

(g)

The individual’s coverage does not provide benefits to individuals who no longer reside, live, or work in a service area and the individual no longer resides, lives, or works in the service area;

(h)

The individual incurs a claim that would meet or exceed a lifetime limit on all benefits;

(i)

The individual’s plan no longer offers any benefits to the class of similarly situated individuals that includes the individual;

(j)

The employer terminates employer contributions to the individual’s coverage; or

(k)

The qualified individual or qualified individual’s dependent, who is enrolled in an employer-sponsored plan, is determined newly eligible for APTC because the employer-sponsored plan is no longer considered minimum essential coverage set forth in 26 CFR §1.36B-2(c)(3), including as a result of the qualified individual’s employer discontinuing or changing available coverage within the next 60 days, if the qualified individual or qualified individual’s dependent is permitted by the employer and applicable federal laws to terminate enrollment in the employer-sponsored plan;

(2)

A qualified individual or the qualified individual’s dependent loses eligibility for employer-sponsored coverage that is COBRA continuation coverage or continuation coverage under State law because:

(a)

The individual exhausted COBRA continuation coverage or continuation coverage under State law;

(b)

The individual’s employer was paying all or part of the premiums and completely ceased contributions to the individual or dependent’s coverage; or

(c)

A governmental entity was subsidizing coverage and completely ceased contributions to the individual or dependent’s coverage; or

(3)

An enrollee or an enrollee’s dependent loses coverage in a QHP because the QHP is decertified.

Loss of minimum essential coverage does not include termination or loss due to:

(1)

Failure to pay premiums on a timely basis, including failure to pay COBRA premiums prior to expiration of COBRA coverage;

(2)

A change in eligibility status under 45 CFR §155.315(f)(5) because the individual does not meet the requirement specified under Regulation .05 of this chapter;

(3)

An authorized carrier’s valid rescission of coverage;

(4)

A loss in coverage from a short-term limited duration insurance plan as stated in Insurance Article, §15-1301(s), Annotated Code of Maryland; or

(5)

A loss in coverage from an association health plan as stated in Insurance Article, §15-1301(c), Annotated Code of Maryland that does not meet the definition for minimum essential coverage as stated in Insurance Article, §15-1301(p), Annotated Code of Maryland.

The date of loss of minimum essential coverage or other coverage is the date the qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent:

(1)

Loses eligibility for minimum essential coverage under the previous plan; or

(2)

The coverage under §A(1)—(4) of this regulation terminates.

To be eligible for a special enrollment period under this regulation, a qualified individual, an enrollee, a qualified individual’s dependent or an enrollee’s dependent shall:

(1)

Report the loss of minimum essential coverage or the termination of coverage under §A(1)—(4) of this regulation;

(2)

Select a QHP:

(a)

Up to 60 days before or within 120 days after the loss of minimum essential coverage through the Maryland State Medicaid Program or the Maryland Children’s Health Insurance Program (CHIP), including the Maryland Children’s Health Program (MCHP) Premium, on August 1, 2024, and beyond; or

(b)

Up to 60 days before or within 60 days after the loss of any other form of minimum essential coverage or the termination of coverage; and

(3)

Provide attestation or documentary evidence from an employer, carrier, legal/court proceeding, public health coverage program, death certificate, or the qualified individual that, together, indicates the date of coverage loss and the qualified individuals losing coverage.

Enrollment in a QHP selected by a qualified individual, an enrollee, or a qualified individual’s dependent during a special enrollment period for loss of minimum essential coverage or termination of coverage under §A(1)—(4) of this regulation shall be effective on:

(1)

The first day of the month following the loss of minimum essential coverage or termination of coverage if the Individual Exchange receives the QHP selection before the loss of minimum essential coverage or the coverage terminates;

(2)

The first day of the month after the Individual Exchange receives the QHP selection if the Individual Exchange receives the QHP selection after the loss of minimum essential coverage or the coverage terminates; or

(3)

Notwithstanding §F(1) and (2), at the option of the consumer, the first day of the month in which the triggering event occurs if the loss of minimum essential coverage occurs mid-month and the plan selection is made on or before the last day of the month preceding the triggering event.

The eligibility for the special enrollment period under §A(4) of this regulation shall only be available once per calendar year for the qualified individual and the qualified individual’s dependent.

Notwithstanding the standards outlined in this regulation and in Regulations .13—.19 of this chapter, if a qualified individual is eligible for advance payments of the premium tax credit or cost-sharing reductions, the advance payment of the premium tax credit or the cost-sharing reduction shall be effective on the qualified individual’s enrollment date.

Regulation .13 Special Enrollment Periods — Change in Family Status Through the Individual Exchange.Link Copy Citation

A qualified individual, an enrollee, a qualified individual’s dependent, and an enrollee’s dependent are eligible for a special enrollment period for change in family status if the qualified individual or enrollee gains a dependent or becomes a dependent through:

(1)

Marriage;

(2)

Birth;

(3)

Adoption;

(4)

Placement for adoption;

(5)

Placement in foster care;

(6)

A child support order; or

(7)

Other court order.

An enrollee is eligible for a special enrollment period for change in family status if the enrollee loses a dependent or is no longer considered a dependent through:

(1)

Divorce;

(2)

Legal separation; or

(3)

Death.

Family status changes shall be determined in accordance with the law of the state where the change in family status occurred.

If eligible for a special enrollment period under this regulation, a qualified individual, an enrollee, a qualified individual’s dependent or an enrollee’s dependent shall select a QHP within 60 days of the change in family status under §§A and B of this regulation.

Enrollment in a QHP selected by a qualified individual, an enrollee, the qualified individual’s dependent, or the enrollee’s dependent during a special enrollment period under this regulation shall be effective:

(1)

For marriages, the first day of the month following the date that the Individual Exchange receives the QHP selection;

(2)

For birth, adoption, placement for adoption, placement in foster care, or court order, on a date chosen by the qualified individual or enrollee that is either:

(a)

The date of birth, adoption, placement for adoption, placement in foster care, or effective date of court order; or

(b)

The first day of the month following the date that the Individual Exchange receives the QHP selection;

(3)

In the case of death, the first day of the month following the date that the Individual Exchange receives the QHP selection; and

(4)

For divorces or legal separation:

(a)

Before January 1, 2025:

(i)

The first date of the following month for QHP selections received by the Individual Exchange between the first and the 15th day of the month; or

(ii)

The first day of the next following month for QHP selections received by the Individual Exchange between the 16th and the last day of a month; or

(b)

On or after January 1, 2025, the first day of the month following the date that the Individual Exchange receives the QHP selection.

Regulation .14 Special Enrollment Period — Error, Misrepresentation, or Inaction through the Individual Exchange.Link Copy Citation

Prior to January 1, 2020, a qualified individual or a qualified individual’s dependent shall be eligible for the special enrollment period set forth in 45 CFR §155.420(c)(3) if the triggering event set forth in 45 CFR §155.420(d)(4) occurs.

Effective January 1, 2020, as evaluated and determined by the Individual Exchange, a qualified individual or qualified individual’s dependent is eligible for a special enrollment period when the individual or dependent’s enrollment or non-enrollment in a QHP is:

(1)

Unintentional, inadvertent, or erroneous; and

(2)

The result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Individual Exchange its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities.

Effective January 1, 2020, a qualified individual or a qualified individual’s dependent shall notify the Individual Exchange of the alleged error, misrepresentation, or inaction by the later of:

(1)

30 days of the alleged error, misrepresentation, or inaction; or

(2)

30 days from when the qualified individual reasonably should have known about the alleged error, misrepresentation, or inaction.

Notification to the Individual Exchange under §C of this regulation shall be satisfied if the qualified individual or qualified individual’s dependent provides notice:

(1)

To an Individual Exchange-certified navigator, an Individual Exchange-authorized broker or an Individual Exchange-certified consolidated service center representative; and

(2)

Using any of the methods of communication listed under Regulation .03B of this chapter.

Effective January 1, 2020, the length of the special enrollment period shall be 60 days from the date that the Individual Exchange notifies the qualified individual or qualified individual’s dependent of their eligibility for a special enrollment period under this regulation.

The effective date of coverage for a qualified individual or the qualified individual’s dependent who is determined eligible for a special enrollment period under this regulation and selects a QHP during the special enrollment period under §E of this regulation:

(1)

Shall be a date determined by the Individual Exchange as appropriate based on the circumstances of the error, misrepresentative, or inaction;

(2)

Shall be no earlier than the date the qualified individual’s or qualified individual’s dependent’s coverage would have begun or continued but for the error, misrepresentation, or inaction; and

(3)

May be retroactive or prospective depending on the nature of the error, misrepresentation, or inaction.

Plan Display Errors.

(1)

A qualified individual, an enrollee, or their dependent is eligible for a special enrollment period if their decision to purchase a QHP through the Exchange was influenced by a material error related to plan benefits, cost sharing, service area, or premium.

(2)

Notwithstanding §§C and D of this regulation, the burden of proof for an error under this section may not fall on the qualified individual or qualified individual’s dependent.

(3)

The length of the special enrollment period under this section shall adhere to the guidance in §E of this regulation.

(4)

The effective date of coverage under this section shall adhere to the guidance in §F of this regulation.

Regulation .15 Special Enrollment Period — Misconduct Through the Individual Exchange.Link Copy Citation

Prior to January 1, 2020, a qualified individual or qualified individual’s dependent is eligible for a special enrollment period set forth in 45 CFR §155.420(c)(3) if the triggering event set forth in 45 CFR §155.420(d)(4) occurs.

Effective January 1, 2020, a qualified individual or qualified individual’s dependent is eligible for a special enrollment period if:

(1)

The Individual Exchange determines, in collaboration and coordination with the Maryland Insurance Administration that, as a result of misconduct on the part of the Individual Exchange, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities, the qualified individual or qualified individual’s dependent:

(a)

Was not enrolled in a QHP;

(b)

Was not enrolled in the QHP selected by the qualified individual, enrollee, or dependent; or

(c)

Is eligible for, but is not receiving APTC or CSR; and

(2)

The qualified individual or qualified individual’s dependent notifies the Individual Exchange or the Maryland Insurance Administration of the alleged misconduct by the later of:

(a)

30 days of the misconduct; or

(b)

30 days of when the qualified individual reasonably should have known about the misconduct.

Misconduct under this regulation means the failure of an officer, employee, or agent of the Individual Exchange, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities to comply with applicable standards set forth in COMAR 14.35 or other applicable State or federal laws as determined by the Individual Exchange, or the Maryland Insurance Administration.

Notification to the Individual Exchange under §B(2) of this regulation shall be satisfied if the qualified individual or qualified individual’s dependent provides notice:

(1)

To an Individual Exchange-certified navigator, an Individual Exchange-authorized broker, or an Individual Exchange-certified consolidated service center representative, and

(2)

Using any of the methods of communication listed under Regulation .03B of this chapter.

Notification to the Maryland Insurance Administration under §B(2) of this regulation shall be satisfied if the qualified individual or the qualified individual’s dependent files a complaint with the Maryland Insurance Administration.

Effective January 1, 2020, the length of the special enrollment period shall be 30 days from the date that the Individual Exchange notifies the qualified individual or the qualified individual’s dependent that the qualified individual or the qualified individual’s dependent is eligible for a special enrollment period under this regulation.

(1)

Shall be determined by the Individual Exchange as appropriate based on the circumstances of the misconduct;

(2)

Shall be no earlier than the date the qualified individual or dependent’s coverage would have begun or continued, but for the misconduct; and

(3)

May be retroactive or prospective depending on the nature of the misconduct.

The Individual Exchange’s determination that an individual is eligible for a special enrollment period under this regulation may be made prior to the completion of the Maryland Insurance Administration’s review of the alleged misconduct.

Regulation .16 Special Enrollment Period — Violation of Material Provision Through the Individual Exchange.Link Copy Citation

Prior to January 1, 2020, an enrollee or an enrollee’s dependent shall be eligible for a special enrollment period set forth in 45 CFR §155.420(c)(3) if the triggering event set forth in 45 CFR §155.420(d)(5) occurs.

Effective January 1, 2020, an enrollee or an enrollee’s dependent is eligible for a special enrollment period if the enrollee or the enrollee’s dependent:

(1)

Demonstrates, as determined by the Individual Exchange in collaboration and coordination with the Maryland Insurance Administration, that the carrier of the QHP in which the enrollee or dependent is enrolled substantially violated a material provision of its contract in relation to the enrollee or the enrollee’s dependent; and

(2)

Notifies the Exchange or the Maryland Insurance Administration of the alleged violation by the later of:

(a)

30 days of the violation; or

(b)

30 days of when the enrollee or dependent reasonably should have known about the violation.

Notification to the Individual Exchange under §B(2) of this regulation shall be satisfied if the enrollee or the enrollee’s dependent provides notice:

(1)

To an Individual Exchange-certified navigator, an Individual Exchange-authorized broker, or an Individual Exchange-certified consolidated service center representative; and

(2)

Using any of the methods of communication listed under Regulation .03B of this chapter.

Notification to the Maryland Insurance Administration under §B(2) of this regulation shall be satisfied if the enrollee or enrollee’s dependent files a complaint with the Maryland Insurance Administration.

Effective January 1, 2020, the length of the special enrollment period shall be 30 days from the date that the Individual Exchange notifies the enrollee or the enrollee’s dependent that the enrollee or enrollee’s dependent is eligible for a special enrollment period under this regulation.

The effective date of coverage for an enrollee or an enrollee’s dependent who is determined eligible for a special enrollment period under this regulation and selects a QHP during the special enrollment period under §E of this regulation:

(1)

Shall be a date determined by the Individual Exchange as appropriate based on the circumstances of the material violation;

(2)

Shall be no earlier than the date the enrollee or enrollee’s dependent’s coverage would have begun or continued, but for the material violation; and

(3)

May be retroactive or prospective depending on the nature of the material violation.

Regulation .17 Special Enrollment Period — Exceptional Circumstances Through the Individual Exchange.Link Copy Citation

Prior to January 1, 2020, an individual, an enrollee or an enrollee’s dependent is eligible for a special enrollment period set forth in 45 CFR §155.420(c)(3) if the triggering event set forth in 45 CFR §155.420(d)(9) occurs.

Effective January 1, 2020, a qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent is eligible for a special enrollment period if:

(1)

The Individual Exchange determines that, at the time of the qualified individual’s, enrollee’s, qualified individual’s dependent’s, or enrollee’s dependent’s application for coverage, the individual experienced exceptional circumstances that prevented the qualified individual, enrollee, qualified individual’s dependent or the enrollee’s dependent from enrolling during open enrollment or a special enrollment period, if the individual was determined eligible for the special enrollment period by the Individual Exchange; and

(2)

The qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent notifies the Exchange within 30 calendar days of the exceptional circumstances.

The Exchange, at its discretion, may waive the 30-calendar-day reporting requirement under §B(2) of this regulation if the exceptional circumstance prevented the qualified individual from providing notice.

Exceptional circumstances may include, but are not limited to:

(1)

A serious medical condition, such as an unexpected hospitalization or temporary cognitive disability;

(2)

Domestic abuse or violence;

(3)

Spousal abandonment;

(4)

A natural disaster, such as an earthquake, a massive flooding, or a hurricane;

(5)

A significant life event resulting in lack of access to the qualified individual’s or enrollee’s Individual Exchange application or account and the qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent has experienced a change in situation or status that now requires that the qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent obtain minimum essential coverage; or

(6)

Policy action that would result in a premium change of prospective coverage that would adversely impact the qualified individual and the qualified individual did not receive reasonable notice to act upon the material change.

Notification to the Individual Exchange under §B(2) of this regulation shall be satisfied if the qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent provides notice:

(1)

To an Individual Exchange-certified navigator, an Individual Exchange-authorized broker, or an Individual Exchange-certified consolidated service center representative; and

(2)

Using any of the methods of communication listed under Regulation .03B of this chapter.

The effective date of coverage for a qualified individual, an enrollee, a qualified individual’s dependent, or an enrollee’s dependent who is determined eligible for a special enrollment period under this regulation and selects a QHP during the special enrollment period under §B of this regulation:

(1)

Shall be a date determined by the Individual Exchange as appropriate based on the circumstances of the qualified individual’s, the enrollee’s, the qualified individual’s dependent’s, or the enrollee’s dependent’s exceptional circumstances;

(2)

Shall be no earlier than the date the qualified individual’s, the enrollee’s, the qualified individual’s dependent’s, or the enrollee’s dependent’s coverage would have begun or continued, but for the exceptional circumstances; and

(3)

May be retroactive or prospective dependent on the nature of the exceptional circumstance.

Regulation .18 Special Enrollment Period — Permanent Move.Link Copy Citation

A qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent is eligible for a special enrollment period if the qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent:

(1)

Gains access to a new QHP as a result of a permanent move;

(2)

Was enrolled in minimum essential coverage for one or more days in the 60 days prior to the move, unless the qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent:

(a)

Lived in a foreign country or a United States territory for 1 or more days during the 60 days preceding the date of the move;

(b)

Is moving from a state that did not expand Medicaid or MCHP eligibility set forth in §2001 of the ACA and the individual was not eligible for APTC or CSR in the individual’s previous state of residence because the individual’s household income was below 100 percent of the FPL; or

(c)

Is leaving incarceration, except if the individual was incarcerated pending disposition; and

(3)

Notifies the Individual Exchange within 60 days from the date of the permanent move that the qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent has gained access to a new QHP as a result of that move.

A permanent move does not include:

(1)

A short-term or temporary move where the qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent does not intend to remain in the individual’s new location; or

(2)

A move solely for the purpose of obtaining medical treatment.

A qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent may select a qualified health plan within 60 days of the date of the permanent move if the individual is otherwise eligible for the special enrollment period.

The effective date of coverage for a qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent who is determined eligible for the special enrollment period under this regulation and selects enrollment in a QHP during the special enrollment period under §C of this regulation shall be:

(1)

Before January 1, 2025:

(a)

The first day of the following month for QHP selections received by the Individual Exchange on or before the date of the permanent move;

(b)

The first day of the following month for QHP selections received by the Individual Exchange after the date of the permanent move between the first and 15th day of a month; or

(c)

The first day of the second following month for QHP selections received by the Individual Exchange after the date of the permanent move between the 16th and the last day of a month; or

(2)

On or after January 1, 2025, the first day of the month following the date that the Individual Exchange receives the QHP selection.

Regulation .19 Special Enrollment Period — Other.Link Copy Citation

An enrollee or an enrollee’s dependent enrolled in the same plan is eligible for a special enrollment period if the enrollee or enrollee’s dependent:

(1)

Is determined newly eligible or ineligible for APTC; or

(2)

Has a change in eligibility for cost-sharing reductions.

A qualified individual or a qualified individual’s dependent is eligible for a special enrollment period if the qualified individual or qualified individual’s dependent:

(1)

Experiences a decrease in household income;

(2)

Is newly determined eligible by the Individual Exchange for APTC; and

(3)

Had minimum essential coverage as described in 26 CFR §1.5000A-1(b) for one or more days during the 60 days preceding the date of the financial change.

A qualified individual, a qualified individual’s dependent, or an enrollee’s dependent is eligible for a special enrollment period through the Maryland Easy Enrollment Health Insurance Program as codified in Md. Code, Ins. §31.202 if they indicate on a state tax return that they:

(1)

Attest to not having health care coverage; and

(2)

Authorize the Comptroller of Maryland to share information from the qualified individual’s tax return with the Maryland Health Benefit Exchange.

A qualified individual or qualified individual’s dependent is eligible for a special enrollment period if the qualified individual or qualified individual’s dependent is confirmed to be pregnant by a health care practitioner.

A qualified individual who is an Indian, or becomes a dependent of an Indian, may enroll in a QHP or change from one QHP to another, no more than once per month.

A qualified individual or a qualified individual’s dependent is eligible for a special enrollment period if the qualified individual or qualified individual’s dependent who was not previously a U.S. citizen, a U.S. national, or lawfully present in the U.S. becomes a U.S citizen, a U.S. national, or lawfully present in the U.S.

A qualified individual or a qualified individual’s dependent is eligible for a special enrollment period if the qualified individual or qualified individual’s dependent who was previously incarcerated becomes newly eligible for a QHP due to satisfying the requirements under 45 CFR §155.305(a)(2).

A qualified individual or qualified individual’s dependent is eligible for a special enrollment period if the qualified individual receives a certificate of exemption under Regulation .20 of this chapter for a hardship based on the eligibility standards set forth in 45 CFR §155.605(d)(i)(iii) for a month or months during the coverage year, and based on the circumstances of the hardship attested to, the qualified individual is no longer eligible for a hardship exemption within a coverage year but outside of an open enrollment period.

A qualified individual or a qualified individual’s dependent is eligible for a special enrollment period if a qualified individual with a certificate of exemption under Regulation .20 of this chapter for a hardship based on the eligibility standards for an exemption, as set forth in 45 CFR §155.620(b), the change resulting from a redetermination is implemented, and the qualified individual or the qualified individual’s dependent is no longer eligible for an exemption.

Individual Coverage Health Reimbursement Arrangements and Qualified Small Employer Health Reimbursement Arrangements.

(1)

A qualified individual, an enrollee, a qualified individual’s dependent, or an enrollee’s dependent is eligible for a special enrollment period if they newly gain access to an individual coverage health reimbursement arrangement (HRA) (as defined in 45 CFR §146.123(b)) or are newly provided a qualified small employer health reimbursement arrangement (QSEHRA) (as defined in §9831(d)(2) of the Internal Revenue Code).

(2)

The triggering event is the first day on which coverage for the qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent under the individual coverage HRA can take effect, or the first day on which coverage under the QSEHRA takes effect.

(3)

A qualified individual, an enrollee, a qualified individual’s dependent, or an enrollee’s dependent qualifies for this special enrollment period regardless of whether they were previously offered or enrolled in an individual coverage HRA or previously provided a QSEHRA, if the qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent is not enrolled in the individual coverage HRA or covered by the QSEHRA on the day immediately prior to the triggering event.

A qualified individual or qualified individual’s dependent is eligible for a special enrollment period if the qualified individual or qualified individual’s dependent:

(1)

Applies for coverage on the Exchange during the annual open enrollment period or due to a qualifying event;

(2)

Is assessed by the Exchange as potentially eligible for Medicaid or MCHP; and

(3)

Is determined ineligible for Medicaid or MCHP by the Department either after open enrollment has ended or more than 60 days after the qualifying event.

A qualified individual, an enrollee, a qualified individual’s dependent or an enrollee’s dependent is eligible for a special enrollment period if the qualified individual or qualified individual’s dependent experiences a change or triggering event not included in this regulation under 45 CFR §155.420.

A qualified individual, an enrollee, a qualified individual’s dependent, or an enrollee’s dependent is eligible to enroll during any month of the year if:

(1)

They are eligible for APTC; and

(2)

Their household income does not exceed 150 percent of the federal poverty line.

Eligibility Windows.

(1)

A qualified individual, an enrollee, a qualified individual’s dependent, or an enrollee’s dependent shall notify the Individual Exchange of the change in circumstances and select a QHP within the following time frames:

(a)

For §§A, B, F, and K of this regulation, 60 days after the date of the event that triggers the special enrollment period;

(b)

For §§E and G—I of this regulation, 60 days before or after the date of the event that triggers the special enrollment period;

(c)

For §C of this regulation (Maryland Easy Enrollment Health Insurance Program), 35 days after the date specified on the SEP notification letter sent to the qualified individual;

(d)

For §D of this regulation (pregnancy), 90 days after the date of confirmation of pregnancy by a health care practitioner; and

(e)

For §J of this regulation, 60 days before the triggering event, unless the HRA or QSEHRA was not required to provide the notice setting forth its terms to such individual or enrollee at least 90 days before the beginning of the plan year, as specified in 45 CFR §146.123(c)(6), 26 CFR §54.9802–4(c)(6), and 29 CFR §2590.702–2(c)(6) or §9831(d)(4) of the Internal Revenue Code, as applicable, in which case the qualified individual, enrollee, or dependent of the individual or enrollee has 60 days before or after the triggering event to select a QHP.

(2)

If a qualified individual, an enrollee, a qualified individual’s dependent or an enrollee’s dependent did not receive timely notice of an event that triggers eligibility for a special enrollment period under this chapter, and otherwise was reasonably unaware that a triggering event described in this chapter occurred, the Exchange shall allow the qualified individual, enrollee, or, when applicable, their dependent to select a new plan within 60 days of the date that they knew, or reasonably should have known, of the occurrence of the triggering event.

(1)

For the special enrollment period under §A of this regulation (newly eligible or ineligible for APTC), §E of this regulation (qualified individual or dependent is an Indian) and §F of this regulation (changes in citizenship status):

(a)

Before January 1, 2025:

(i)

The first day of the month after the Individual Exchange receives the QHP selection when the plan has been selected between the first and the 15th of the month; or

(ii)

The first day of the following month after the Individual Exchange receives the QHP selection when the plan has been selected between the 16th and the last day of the month; or

(b)

On or after January 1, 2025, the first day of the month following the date that the Individual Exchange receives the QHP selection.

(2)

For the special enrollment period under §D of this regulation (pregnancy):

(a)

The first day of the month in which pregnancy is confirmed, including retroactive coverage dates; or

(b)

The first day of the month in which the QHP selection is received by the Individual Exchange;

(3)

For the special enrollment period under §G of this regulation (previously incarcerated) and §J of this regulation (newly eligible for an individual coverage HRA or a QSEHRA):

(a)

Before January 1, 2025:

(i)

The first day of the month following the triggering event for QHP selections received by the Individual Exchange before the release date or before the triggering event; or

(ii)

The first day of the following month for QHP selections received by the Individual Exchange after the release date or the triggering event; or

(b)

On or after January 1, 2025:

(i)

The first day of the month following the date that the Individual Exchange receives the QHP selection; or

(ii)

On the date of the triggering event, if the triggering event is on the first day of a month;

(4)

For the special enrollment period under §K of this regulation (Medicaid or MCHP ineligibility determination), an appropriate date determined by the Exchange based on the circumstances of the special enrollment period; and

(5)

For special enrollment periods under §B, §C (Maryland Easy Enrollment Health Insurance Program), §L (change or triggering event not included in this regulation under 45 CFR §155.420), and §M (eligible for APTC and household income does not exceed 150 percent of the federal poverty line), the first day of the month following the date that the Individual Exchange receives the QHP selection.

Notwithstanding §O, in the case of untimely notice of a triggering event as described in §N(2) of this regulation, a qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent shall have the option of the earliest effective date that would have been available based on the applicable triggering event under this chapter.

Regulation .20 Exemptions.Link Copy Citation

As set forth in 45 CFR §155.625(b), the Individual Exchange has delegated administration of all exemption determinations for Maryland residents to HHS.

An applicant shall follow:

(1)

The procedures specified by HHS to apply for an exemption set forth in 45 CFR Part 155, Subpart G; and

(2)

The procedures specified by the Internal Revenue Service to apply for an exemption under 26 CFR §1.5000A-3.

The Individual Exchange may administer exemption determinations for Maryland residents.

If §C becomes effective, applicants shall follow the procedures specified by the Individual Exchange to apply for an exemption set forth in 26 CFR §1.5000A-3 and 45 CFR Part 155, Subpart G.

Regulation .21 Authorized Representative.Link Copy Citation

An applicant or enrollee in the Individual Exchange may designate an individual or an organization to act as the applicant or enrollee’s representative as set forth in COMAR 14.35.11.14.

Regulation .22 Medicaid to Private Plan Enrollment Program.Link Copy Citation

To the extent permissible by federal law, the Exchange shall enroll an individual into a QHP if the individual was enrolled in Medicaid or MCHP through the Exchange and loses Medicaid or MCHP eligibility after:

(1)

A redetermination based on a change in circumstances reported after April 15, 2023, pursuant to which the individual is determined eligible for a QHP but does not enroll in a QHP following receipt of the QHP eligibility determination; or

(2)

A renewal conducted between April 15, 2023, and April 30, 2024, provided the Exchange verifies that the individual’s most recent attested income exceeds the Medicaid-eligible amount as described in Health-General Article, §15-103(a)(2), Annotated Code of Maryland, and the individual meets eligibility requirements under this chapter to enroll in a QHP.

The Exchange shall select a plan for an individual described in §A(1) of this regulation on a date no earlier than the seventh day after the date of the QHP eligibility determination.

To the extent permissible by federal law, the Exchange shall select a plan for an individual described in §A(2) of this regulation on a date no earlier than the day immediately following the day that the individual’s Medicaid coverage terminates.

The QHP into which the Exchange enrolls an individual shall be determined by the Exchange using the following guidance:

(1)

For an individual who has tax household members who are already enrolled in a QHP, the Exchange shall enroll the individual into the household QHP.

(2)

For an individual who is eligible for a CSR plan for up to 150 percent FPL or a CSR plan for 151—200 percent FPL and does not have tax household members already enrolled in a QHP, the Exchange shall enroll the individual in:

(a)

The lowest-cost Silver plan in the individual's region, if the individual’s former managed care organization does not have an affiliate offering QHPs in that region; or

(b)

The lowest-cost Silver plan offered by an affiliate of the individual’s former managed care organization, if an affiliate offers a QHP in the individual’s region.

(3)

For an individual who is not eligible for a CSR plan for up to 150 percent FPL or a CSR plan for 151—200 percent FPL and does not have tax household members already enrolled in a QHP, the Exchange shall enroll the individual in a plan based on the following guidance:

(a)

If an affiliate of the individual’s former managed care organization offers QHPs in the individual’s region, the Exchange shall enroll the individual in the lower-cost option of either:

(i)

The lowest-cost Gold plan offered by the managed care organization affiliate; or

(ii)

The lowest-cost Silver plan offered by the managed care organization affiliate.

(b)

If an affiliate of the individual’s former managed care organization does not offer QHPs in the individual’s region, the Exchange shall enroll the individual in the lower-cost option of either:

(i)

The lowest-cost Gold plan in the region; or

(ii)

The lowest-cost Silver plan in the region.

For plans selected for an individual under §A(1) of this regulation, enrollment shall be effective on:

(1)

The first day of the month following the date of QHP selection pursuant to §B of this regulation, if the selected plan has a premium greater than zero dollars; or

(2)

The first day of the month following the individual’s confirmation of enrollment, if the selected plan has a premium of zero dollars.

To the extent permissible by federal law, for plans selected for an individual under §A(2) of this regulation, enrollment shall be effective on:

(1)

The first day of the month following the date of QHP selection pursuant to §C of this regulation, if the selected plan has a premium greater than zero dollars; or

(2)

The first day of the month following the individual’s confirmation of enrollment, if the selected plan has a premium of zero dollars.

References to “cost” under this regulation mean premium cost to the consumer after APTCs and State-based subsidies are applied.

Regulation .23 QHP Re-Enrollments—In General.Link Copy Citation

The Exchange shall redetermine the eligibility of a qualified individual on an annual basis as specified in 45 CFR §155.335.

The Exchange shall provide a qualified individual with an annual redetermination notice as specified in 45 CFR §155.335(c) that adheres to the timing specified in 45 CFR §155.335(d).

If an enrollee remains eligible for enrollment in a QHP through the Exchange upon annual redetermination, the Exchange shall re-enroll the enrollee according to 45 CFR §155.335(j), except as provided for in §E of this regulation.

Consumers eligible for re-enrollment may:

(1)

Change their plan during open enrollment;

(2)

If ineligible for automatic re-enrollment, manually re-enroll coverage by:

(a)

Re-enrolling online through the Maryland Health Connection Consumer Portal;

(b)

Re-enrolling with the assistance of an Individual Exchange Navigator, certified application counselor, or insurance producer; or

(c)

Calling the MHC call center; or

(3)

Decline re-enrollment.

Re-Enrollment into Higher Value Plans.

(1)

Unless the enrollee terminates coverage, including termination of coverage in connection with voluntarily selecting a different QHP in accordance with 45 CFR §155.430, the exchange shall follow the procedure detailed in §E(2) of this regulation to re-enroll an enrollee into a plan other than the enrollee's original plan or plan identified by the carrier pursuant to §F of this regulation if the enrollee:

(a)

Remains eligible for enrollment in a QHP through the Exchange upon annual redetermination;

(b)

Is determined, upon annual redetermination, eligible for cost-sharing reductions in accordance with 45 CFR §155.305(g);

(c)

Is currently enrolled in a bronze level QHP that is not a high deductible health plan compatible with a health savings account as defined in 26 U.S.C. §223; and

(d)

Would be re-enrolled in a bronze level QHP that is not a high deductible health plan compatible with a health savings account as defined in 26 U.S.C. §223 under §B of this regulation.

(2)

The Exchange shall re-enroll enrollees that meet the criteria of §E(1) of this regulation in the QHP:

(a)

With the highest actuarial value available;

(b)

Within the same product;

(c)

With the same provider network; and

(d)

Which, compared to the original bronze level QHP into which the Exchange would otherwise re-enroll the enrollee under §B of this regulation, and after the application of advance payment of the premium tax credit and young adult subsidy under COMAR 14.35.19, has a premium that is:

(i)

Lower; or

(ii)

Equivalent.

For QHPs that carriers plan to discontinue, enrollees in those QHPs shall be re-enrolled into QHPs determined by carrier-submitted plan re-enrollment templates according to COMAR 14.35.15.05O.

Chapter 08. Captive Producer Training and Authorization Standards

Chapter 09. Consolidated Service Center Employee Training and Permit Standards

Regulation .01 Scope.Link Copy Citation

This chapter sets forth the qualifications, training, and permit standards for an individual who applies to receive a Consolidated Service Center enrollment permit for the Individual Exchange and is required under Insurance Article, §31-113.1(c), Annotated Code of Maryland, to hold an Individual Exchange enrollment permit.

Regulation .02 Definitions.Link Copy Citation

In this subtitle, the following terms have the meanings indicated.

Terms Defined.

(1)

“Administration” means Maryland Insurance Administration.

(2)

“Commissioner” means the Maryland Insurance Commissioner.

(3)

“Consolidated Service Center” or “CSC” has the meaning stated in Insurance Article, §31-101(c-2), Annotated Code of Maryland.

(4)

“Department” means the Maryland Department of Health.

(5)

“Exchange” has the meaning stated in Insurance Article, §31-101(c), Annotated Code of Maryland.

(6)

“Individual Exchange” has the meaning stated in Insurance Article, §31-101(h), Annotated Code of Maryland.

Regulation .03 Eligibility Requirements.Link Copy Citation

To qualify for an Individual Exchange CSC enrollment permit, an applicant shall meet the requirements set forth under Insurance Article, §31-113.1(c)(3), Annotated Code of Maryland.

Regulation .04 Application Procedures.Link Copy Citation

In order to obtain an Individual Exchange CSC enrollment permit, the applicant shall submit to the Exchange all required materials set forth under COMAR 14.35.02.03A.

The Exchange may not consider an application to be complete until it has received all required materials.

If the application is not completed with all required materials within 45 days after the Exchange receives the signed application form, the Exchange may consider the application withdrawn.

Regulation .05 Training Requirements.Link Copy Citation

In order to obtain an Individual Exchange CSC enrollment permit, an individual shall:

Complete the training program specified under Insurance Article, §31-113(k), Annotated Code of Maryland, and COMAR 14.35.02.04A; and

Successfully pass the examination specified under COMAR 14.35.02.04D.

Regulation .06 General Permit Requirements.Link Copy Citation

Term. An Individual Exchange CSC enrollment permit expires 2 years after the date it is issued unless it is renewed.

Renewal. A CSC employee holding an Individual Exchange CSC enrollment permit shall apply for renewal of the permit in accordance with the requirements set forth under COMAR 14.35.03.02.

Suspension or Revocation.

(1)

The Commissioner may suspend or revoke an Individual Exchange CSC enrollment permit for the reasons listed under Insurance Article, §31-113(l)(1), Annotated Code of Maryland.

(2)

An Individual Exchange CSC enrollment permit is no longer valid upon an individual’s voluntary or involuntary termination from employment or engagement by the Consolidated Services Center.

Chapter 10. Appeals from Determinations Regarding Producer Authorization or Individual Exchange Navigator Certification

Regulation .01 Scope.Link Copy Citation

This chapter applies to contested case hearings delegated by the Board to the Office in accordance with State Government Article, §10- 205(a)(1)(ii), Annotated Code of Maryland.

Except as explicitly stated in this chapter, COMAR 28.02.01 governs the conduct of a hearing before the Office of Administrative Hearings.

Determinations entitled to contested case appeals. This chapter applies only to the appeal of an Exchange determination regarding:

(1)

Suspension of SHOP Exchange producer authorization;

(2)

Revocation of SHOP Exchange producer authorization;

(3)

Renewal of SHOP Exchange producer authorization;

(4)

Suspension of Individual Exchange producer authorization;

(5)

Revocation of Individual Exchange producer authorization;

(6)

Renewal of Individual Exchange producer authorization; and

(7)

Denial of Individual Exchange initial navigator certification.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

“Administrative law judge” has the meaning set forth under COMAR 28.02.01.02B(1).

(2)

“Board means the Maryland Health Benefit Exchange Board of Trustees.

(3)

Contested Case.

(a)

Contested case” has the meaning stated in State Government Article, §10-202(d), Annotated Code of Maryland.

(b)

“Contested case” includes a proceeding:

(i)

Arising out of a determination made by the Board;

(ii)

Regarding an authorization, certification, or permit issued by the Exchange; or

(iii)

Arising out of any act of or failure to act by the Board, involving an authorization or a certification issued by the Exchange, that aggrieves a person.

(c)

“Contested case” does not include any other quasi-legislative hearing.

(4)

Determination.

(a)

“Determination” means a decision by the Board that requires the Board to provide the opportunity for a hearing to a person aggrieved by the decision.

(b)

“Determination” includes:

(i)

A decision as to whether a person against whom an administrative complaint has been received violated a law, regulation, or order; and

(ii)

An order issued pursuant to the Board’s authority.

(5)

“Exchange” means the Maryland Health Benefit Exchange.

(6)

“Executive Director” means the Executive Director of the Maryland Health Benefit Exchange, appointed pursuant to Insurance Article, §31-105, Annotated Code of Maryland.

(7)

“Hearing officer” means the Board or the Board’s authorized designee.

(8)

“Maryland Health Benefit Exchange” has the meaning set forth under Insurance Article, §31-101(e), Annotated Code of Maryland.

(9)

“Office” means the Office of Administrative Hearings.

(10)

“Person” has the meaning set forth under COMAR 28.02.01.02B(12).

Regulation .03 Request for Hearing — In General.Link Copy Citation

Scope. This regulation applies to all requests for a hearing permitted under Regulation .01C of this chapter.

A person aggrieved may request a hearing by submitting a written statement to the Office, signed by the requesting person and containing the following information:

(1)

The action or nonaction of the Exchange causing the person requesting the hearing to be aggrieved;

(2)

The facts related to the incident or incidents about which the person requests the Exchange to act or not to act; and

(3)

The ultimate relief requested.

Request to Be Received Within 30 Calendar Days.

(1)

The request shall be received by the Office within 30 days of the date of the letter notifying the party of the Exchange’s action, intention to act, or failure to act.

(2)

In calculating the 30-day period, the date of the letter notifying the party of the Exchange’s action, intention to act, or failure to act is not included.

(3)

The end of a day is considered to be 11:59 p.m. Eastern Time.

(4)

The last day of the 30-day period is included unless it is a Saturday, Sunday, legal holiday, or day that the Office of Administrative Hearings is closed for a part of the day.

(5)

If the last day of the 30-day period is a Saturday, Sunday, legal holiday, or a day that the Office of Administrative Hearings is closed for a part of the day, the 30-day period runs until the end of the next day which is not a Saturday, Sunday, legal holiday, or day that the Office of Administrative Hearings is closed for a part of the day.

(6)

Intermediate Saturdays, Sundays, legal holidays, and days that the Office of Administrative Hearings is closed for a part of the day shall be counted toward the 30-day period.

Upon receipt of a proper request, the Office shall grant a hearing unless, in viewing the facts set forth by the person making the request, in the light most favorable to that person, the Office determines that:

(1)

The Office has no authority to take action;

(2)

The request does not contain the information required by these regulations;

(3)

The request is untimely; or

(4)

The request is moot.

Regulation .04 Delegation of Authority.Link Copy Citation

Scope. This regulation applies to all requests for a hearing permitted under Regulation .01C of this chapter.

In accordance with State Government Article, §10-205(a)(1)(ii), Annotated Code of Maryland, the Board delegates to the Office the authority to:

(1)

Conduct a contested case hearing; and

(2)

Issue:

(a)

Final findings of fact and conclusions of law; and

(b)

A proposed order.

The Board may revoke all or part of a delegation of authority to preside over a hearing if:

(1)

The case:

(a)

Involves novel or unanticipated factual or legal issues;

(b)

Has significant social, fiscal, or legal issues;

(c)

Involves policy issues; or

(d)

Requires further investigation; or

(2)

The Board determines that revocation of all or part of the delegation of authority is otherwise in the public interest.

Procedure for Revocation.

(1)

The Board shall provide written notice of a revocation of hearing authority to all parties and the entity conducting the contested case hearing under State Government Article, §10-205(a)(1)(ii), Annotated Code of Maryland.

(2)

The written notice shall contain a brief statement of the reason for the revocation.

(3)

Delegation of authority to hear a contested case may be revoked at any time before the earlier of the:

(a)

Issuance of a ruling by the entity delegated authority to conduct a contested case hearing under §A of this regulation on a substantive issue; or

(b)

Taking of oral testimony from the first witness.

(4)

The Board shall specify whether all or part of the delegation to hear a contested case has been revoked.

(5)

If only part of the delegation has been revoked, the Board shall specify in the written notice of revocation the portions of the contested case for which the delegation has been revoked.

(6)

On revocation of the delegation, the Board shall:

(a)

Cause further investigation;

(b)

Set the contested case for a hearing with the Board or the Board's designee acting as the hearing officer as permitted under State Government Article, §10-205(a)(1)(ii), Annotated Code of Maryland; or

(c)

Dismiss the contested case.

Regulation .05 Service of Notices, Decisions, Orders, and Other Documents.Link Copy Citation

The Office shall provide notice of a hearing, decisions, orders and other documents issued by the Office pursuant to State Government Article, §§10-208 and 10-209, Annotated Code of Maryland.

A hearing may be rescheduled if there is satisfactory showing that the notice was sent not less than 30 calendar days before the hearing, or upon agreement of all parties.

Regulation .06 Default Orders.Link Copy Citation

With respect to hearings conducted on behalf of the Exchange, a hearing officer may issue a proposed default order against a party other than the Exchange that, after receiving proper notice, fails to appear at a hearing if:

(1)

Notice is issued by the Office, and the party failing to appear is the person against whom the notice was issued; or

(2)

In any other contested case hearing, the party failing to appear is the person that requested the hearing.

In a hearing arising out of a notice or determination issued by the Exchange, the proposed default order shall:

(1)

State the facts supporting the finding of proper notice to the person against whom the notice or determination was issued;

(2)

Adopt the facts and violations of law as alleged by the Exchange in its notice or determination as if by admission of the person against whom the charging document, order or notice was issued; and

(3)

Adopt the sanction requested by the Exchange at the hearing.

The hearing officer shall serve the proposed default order directly on the parties by certified mail.

Within 15 calendar days after service of a proposed default order, the party in default may submit to the Board a written motion:

(1)

Requesting that the proposed default order be vacated or modified; and

(2)

Stating the grounds for the request.

If the Board finds that there is:

(1)

Good cause to excuse the default, the Board may:

(a)

Vacate or modify the default order; and

(b)

Schedule the case for further appropriate proceedings; or

(2)

No good cause to excuse the default, the Board shall:

(a)

Deny the motion; and

(b)

Affirm the proposed default order as the final order.

Regulation .07 Administrative Decisions.Link Copy Citation

Contents. The hearing officer shall submit to the Board a decision that contains:

(1)

Final findings of fact and conclusions of law; and

(2)

A proposed order.

Effect of Regulations, Bulletins, and Preexisting Policies. In making a decision, the Office is bound by any regulation, bulletin, final order, or settled and preexisting policy of the Board to the same extent that the Board is or would have been bound if the Board were hearing the case.

Distribution of Decision. The Office shall send its decision directly to the parties and the Board.

Regulation .08 Exceptions.Link Copy Citation

On receipt of a decision that contains proposed findings of fact, proposed conclusions of law, or a proposed order, the parties affected have:

(1)

20 calendar days after receipt to request to present argument, file exceptions to the proposed order with the Board, or both of these; or

(2)

10 calendar days to:

(a)

File a written request for a transcript, at the party’s own expense, with the Board in order to file exceptions; or

(b)

File with the Board a copy of that party's written request to its stenographer, at the party’s own expense, for the party's preparation of a transcript based on its own record of the testimony in order to file exceptions.

Receipt under §A of this regulation is presumed to occur 3 calendar days after the mailing of the proposed order.

Filing Exceptions After Receipt of Transcript.

(1)

If a party requests a transcript under §A(2) of this regulation, the party shall have 30 calendar days after the filing of the transcript to file a request to present argument, exceptions, or both of these with the Board.

(2)

Unless extended by order of the Board, the party requesting the transcript shall file the transcript with the Board within 60 calendar days after the date on which the transcript was requested.

Exceptions shall be in writing unless specified otherwise by the Board.

If a party elects not to offer argument or file exceptions, another party may not raise the defense of failure to exhaust this administrative remedy on appeal to circuit court.

If a party requests the opportunity to offer argument, the Board shall grant the request and allow the party to present argument to a majority of the Board.

The record before the Board for the exceptions shall consist of:

(1)

The Office’s findings and conclusions, including the findings of fact, conclusions of law, and proposed order;

(2)

Any exceptions filed by a party;

(3)

Any response to exceptions filed by a party;

(4)

Any evidence submitted by a party;

(5)

Notice to the parties of the hearing;

(6)

Any documentary evidence admitted into evidence by the Office; and

(7)

The transcript of the hearing before the Office, if requested and filed by one of the parties or the Board.

Transcripts.

(1)

A party who desires to have the transcript made part of the record shall, at the party's own expense, file three copies of the transcript, or its relevant portions, with the Board on receipt of the transcript.

(2)

If a transcript has already been prepared, the Board shall make the transcript part of the record in the contested case.

(3)

If a transcript is prepared based on the Office’s record of the testimony and a transcript is prepared based on a party's own record of the testimony, the transcript based on the Office’s record of the testimony is:

(a)

The official transcript; and

(b)

Controlling in the event of any conflict between the two transcripts.

(4)

If the transcript is not filed or otherwise made part of the record in the contested case, parties may not refer in their exceptions to any testimony before the Office not incorporated into the Office’s findings and conclusions.

(5)

If all parties agree that the questions presented for review to the final decision maker can be determined without an examination of the entire transcript, the parties may file a statement showing how the questions arose and setting forth the facts or allegations that are essential to a determination of those issues.

Regulation .09 Final Order Following Proposed Decision.Link Copy Citation

Issuance. After consideration of the Office’s proposed order, and any exceptions filed by the parties, the Board shall issue a final order or a remand order.

Effect of Proposed Order. In reviewing the Office’s proposed order, the Board is:

(1)

Bound by the findings of fact that are supported by competent, material, and substantial evidence; and

(2)

Not bound by any legal analysis, conclusions of law, or proposed order.

Types of Action by the Board. The Board may affirm, reverse, or modify the findings of fact that are supported by competent, material, and substantial evidence, conclusions of law, or proposed order, or remand the case to the Office for further proceedings by setting forth, with particularity, the basis for the Board’s reversal, modification, or remand.

Procedure When Case Remanded. If the Board remands the case for further proceedings, the Board may:

(1)

Refer the case back to the Office; or

(2)

Retain the case to be heard by the Board.

Rehearing. The Board may, on the Board's own motion, hold a rehearing.

Service of Order. The Board shall serve a copy of the final order or remand order on the parties, the parties' attorneys of record, and the entity by first-class mail.

Effect of Summary Affirmance.

(1)

If the Board issues a final order that summarily affirms the proposed order of the Office without discussing the facts and legal issues and without expressly adopting the Office’s legal analysis and conclusions of law, neither the final order nor the proposed order is precedent within the rule of stare decisis.

(2)

Notwithstanding §G(1) of this regulation, a final order of the Board that summarily affirms the proposed order of the Office without discussing the facts and legal issues and without expressly adopting the Office’s legal analysis and [proposed] conclusions of law may be cited and relied on in a proceeding before the Board, the Office, or a court:

(a)

When relevant under the doctrine of the law of the case, res judicata, or collateral estoppel; or

(b)

In any subsequent disciplinary proceeding involving a party to the final order.

(3)

If a party appeals from a final order of the Board that summarily affirms the proposed order of the Office, in addition to filing the final order of the Board with the court in which the appeal is pending, the Board also shall file a copy of the proposed order of the Office.

Regulation .10 Decisions.Link Copy Citation

The Board shall sign the final order, and the order is effective when issued unless a different date is specified in the decision. A copy of the final order shall be filed with the Exchange and served on all parties to the hearing.

Regulation .11 Mistake or Error in the Final Order.Link Copy Citation

The Board may correct an order if, upon review, the final order was issued as a result of fraud, mistake, or inadvertence or contains a clerical error.

Regulation .12 Judicial Review.Link Copy Citation

A party adversely affected by a final decision of the Board, or the entity delegated authority to make the final decision, may obtain judicial review of the decision as provided by law.

Chapter 11. Fair Hearings of Individual Exchange Eligibility Determinations

Regulation .01 Scope.Link Copy Citation

This chapter applies to eligibility determinations and redeterminations for enrollment in qualified health plans, advance payments of the premium tax credit, cost-sharing reductions, and State-based subsidies offered through the Individual Exchange, as well as for MAGI-based eligibility determinations and redeterminations for the Maryland State Medicaid program and the Maryland Children’s Health Insurance Program.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

“Administrative law judge” means an individual appointed by the Chief Administrative Law Judge under State Government Article, §9-1604, Annotated Code of Maryland, or designated by the Chief Administrative Law Judge under State Government Article, §9-1607, Annotated Code of Maryland, to adjudicate contested cases at the Maryland Office of Administrative Hearings.

(2)

“Affordable Care Act” means the Patient Protection and Affordable Care Act of 2010 (Pub.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub.L. 111-152), as amended by the Three Percent Withholding Repeal and Job Creation Act (Pub.L. 112-56).

(3)

“Appellant” means any individual who requests a fair hearing for the reasons specified in Regulation .03 of this chapter or that individual’s authorized representative, whether regarding an initial determination or a redetermination.

(4)

“Authorized representative” has the same meaning as in Regulation .14 of this chapter.

(5)

“Catastrophic plan” means a plan established under §1302(e) of the Affordable Care Act.

(6)

“Consolidated Services Center” means the call center operated by the Maryland Health Benefit Exchange to assist consumers who apply for, or participate in, a qualified health plan or the insurance affordability programs offered through the Maryland Health Connection.

(7)

“Delegate agency” means the Department of Human Services and its affiliate local departments which, under contractual agreements with the Department, determine initial and continuing eligibility in the Program.

(8)

“Department” means the Maryland Department of Health, the single State agency which, pursuant to Title XIX of the Social Security Act, implements fair hearing requirements for Program applicants and recipients.

(9)

“Individual Exchange” has the meaning stated in Insurance Article, §31-101(h), Annotated Code of Maryland.

(10)

“Insurance affordability program” means a program that is one of the following:

(a)

The Maryland State Medicaid program;

(b)

The Maryland Children’s Health Insurance Program (CHIP), including the program known as Maryland Children’s Health Program (MCHP) Premium;

(c)

A State basic health program established under §1331 of the Affordable Care Act;

(d)

A program that makes available to eligible individuals coverage in a qualified health plan through the Maryland Health Benefit Exchange with advance payments of the premium tax credit established under §36B of the Internal Revenue Code;

(e)

A program that makes available to eligible individuals coverage in a qualified health plan through the Maryland Health Benefit Exchange with cost-sharing reductions established under §1402 of the Affordable Care Act; or

(f)

The State-Based Young Adult Health Insurance Subsidies Program established under Insurance Article, §31-122, Annotated Code of Maryland.

(11)

“MAGI” means modified adjusted gross income, as calculated for purposes of determining or redetermining eligibility for insurance affordability programs under the Affordable Care Act, as defined in 26 CFR §1.36B-1(e)(2).

(12)

“Maryland Health Benefit Exchange” or “Exchange” means the unit of State government that determines initial and continuing eligibility for the MAGI-based insurance affordability programs, including, by delegation, certain eligibility in the Program.

(13)

“Maryland Health Connection” means the electronic eligibility system maintained by the Maryland Health Benefit Exchange.

(14)

“Program” means the Department’s Medical Assistance Program.

(15)

Qualified Health Plan.

(a)

“Qualified health plan” means a health benefit plan that has been certified by the Maryland Health Benefit Exchange to meet the criteria for certification described in §1311(c) of the Affordable Care Act and Insurance Article, §31-115, Annotated Code of Maryland.

(b)

“Qualified health plan” includes a catastrophic plan.

Regulation .03 Opportunity for a Fair Hearing.Link Copy Citation

An opportunity for a fair hearing shall be granted if an applicant claims that:

(1)

The determination or redetermination received from the Exchange of the applicant’s eligibility for enrollment in a qualified health plan is incorrect;

(2)

The determination or redetermination received from the Exchange of the applicant’s eligibility for an insurance affordability program is incorrect; or

(3)

The determination or redetermination received from the Exchange of the applicant’s eligibility for enrollment in a qualified health plan or an insurance affordability program is untimely as set forth in applicable law.

The administrative law judge need not grant a fair hearing if the sole issue is a federal or State law requiring an automatic change adversely affecting some or all applicants.

Regulation .04 Notification of Right to Request a Fair Hearing.Link Copy Citation

The Exchange shall notify an individual and the individual’s authorized representative, if previously designated by the individual or recognized as valid by the Exchange, in writing:

(1)

Of the right to obtain a fair hearing;

(2)

Of the method to obtain the hearing;

(3)

That the individual may represent the individual or use an authorized representative at a fair hearing;

(4)

Of the circumstances under which the individual’s eligibility may be maintained or reinstated pending an appeal decision; and

(5)

That an appeal decision for one household member may result in a change in eligibility for other household members, and that such a change will be handled as a redetermination of eligibility for other household members.

The notification specified in §A of this regulation shall:

(1)

Be provided by the Exchange when:

(a)

The individual applies for enrollment in a qualified health plan and, if applicable, for an insurance affordability program; or

(b)

Any Exchange action affects the individual’s claim to enrollment in a qualified health plan, or to eligibility for, or the amount of, an insurance affordability program.

(2)

Include a statement of the action the Exchange intends to take;

(3)

Include the reasons for the intended action;

(4)

Include the specific regulations that support, or the change in federal or State law that requires, the action;

(5)

To the extent required by law for Program benefits, include an explanation of the individual’s right to request a fair hearing, including that expenses incurred in connection with a fair hearing, such as transportation and baby-sitting costs, but not including attorney’s fees, shall be paid by the Department when incurred by the appellant and may be paid by the Department when incurred by the appellant’s witnesses;

(6)

Include information about fair hearings;

(7)

Include an explanation of the circumstances under which Program benefits are continued if a fair hearing is requested as provided in Regulation .05 of this chapter;

(8)

Identify who may act as an authorized representative of the appellant in the fair hearing process, explain how an applicant may designate an authorized representative, and provide information about designation procedures under Regulation .14 of this chapter;

(9)

Specify that the appellant or the appellant’s authorized representative may examine the appellant’s records upon reasonable notice to the Exchange; and

(10)

For termination of Program benefits, be mailed at least 10 days before the date of action except as specified under COMAR 10.01.04.03C.

The notice specified in §A of this regulation shall be mailed in accordance with 45 CFR §155.310(g) if the action is a determination or redetermination regarding eligibility for enrollment in a qualified health plan or eligibility for an insurance affordability program described in Regulation .02B(10)(d) or (e) of this chapter.

Regulation .05 Request for Fair Hearing.Link Copy Citation

Statement of Request.

(1)

Any individual, either personally or through an authorized representative, may request a fair hearing by giving a clear statement, oral, electronic, or written, that the individual desires an opportunity to present for review any matter which is the proper subject of a fair hearing as provided in Regulation .03 of this chapter. The request shall be made by:

(a)

Contacting the Exchange in writing, by mail, telephone, email, or fax;

(b)

Contacting the Consolidated Services Center maintained by the Exchange by mail, telephone, or fax;

(c)

Contacting the delegate agency in person or by mail, telephone, or fax;

(d)

Contacting the Department’s Office of Health Services in person or by mail, telephone, or fax; or

(e)

Contacting the Office of Administrative Hearings in person, or by mail or fax.

(2)

The Program’s Office of Health Services, the Exchange, the Consolidated Services Center, or the delegate agency that is contacted by an appellant or the appellant’s authorized representative about requesting a hearing shall assist the appellant or the appellant’s authorized representative in preparing the request.

(3)

The Program’s Office of Health Services, the Exchange, the Consolidated Services Center, or the delegate agency that receives or prepares a written statement on behalf of the appellant or the appellant’s authorized representative requesting an appeal shall:

(a)

Immediately forward an applicant’s statement to the Office of Administrative Hearings;

(b)

Indicate whether the appeal is for a determination or redetermination of eligibility to enroll in a qualified health plan or eligibility for an insurance affordability program, if known; and

(c)

Note in its correspondence with the Office of Administrative Hearings if the appeal:

(i)

Concerns an immediate need for health services where the appellant’s life, health, or ability to attain, maintain, or regain maximum function would be jeopardized by the standard appeal process; and

(ii)

To the extent required by applicable law, must be heard and decided within 3 working days after the Office of Administrative Hearings receives the fair hearing request.

(4)

If a request for a hearing is made by someone other than the applicant, the Office of Administrative Hearings shall:

(a)

Treat the appeal as timely noted if it complies with §D of this regulation, provided documentation pursuant to §A(4)(b) is provided on or before the hearing date, except that no documentation shall be required for representation pursuant to §A(4)(c) of this regulation;

(b)

Accept appropriate documentation, up to and including the date of the fair hearing, demonstrating that the representative is authorized; and

(c)

Accept the representation of any member of the bar of Maryland that the individual appellant is the member’s client without further documentation.

Acknowledgement. The Office of Administrative Hearings shall:

(1)

Send timely acknowledgement to the appellant, and the appellant’s authorized representative, if applicable, of the receipt of the fair hearing request;

(2)

Give advance notice in writing of the date, time, and place of the fair hearing;

(3)

Provide the appellant with the information specified in Regulation .04A(4) of this chapter; and

(4)

Provide an explanation that any advance payments of the premium tax credit paid on behalf of the appellant pending appeal are subject to reconciliation pursuant to 26 CFR §1.36B-4.

Postponements.

(1)

If any party notifies the Office of Administrative Hearings that either the time or place designated by the Office of Administrative Hearings is not convenient to the party, and requests a different time or place for the fair hearing, the administrative law judge shall designate another time or place convenient to the parties if the administrative law judge deems that the party has sufficient reason for requesting the change.

(2)

If the appellant is employed during the periods when fair hearings are normally held, the administrative law judge shall attempt to schedule the hearing so that the appellant will not be required to miss employment.

Timeliness of Appeal. A request for a fair hearing may not be granted unless the request pursuant to §A of this regulation is filed within 90 days of the receipt of the notification specified in Regulation .04A of this chapter, in one of the following methods:

(1)

Postmarked, delivered in person, or faxed to the Office of Administrative Hearings;

(2)

Postmarked, emailed, telephoned, or faxed to the Exchange;

(3)

Postmarked, telephoned, or faxed to the Consolidated Services Center;

(4)

Postmarked, delivered in person, telephoned, or faxed to the delegate agency; or

(5)

Postmarked, delivered in person, telephoned, or faxed to the Department’s Office of Health Services.

Dismissal.

(1)

The Exchange or the Office of Administrative Hearings may dismiss a request for a fair hearing when the appeal has been:

(a)

Withdrawn in writing, either electronically or in hard copy; or

(b)

Abandoned.

(2)

An appellant shall be deemed to have abandoned the appellant’s request for a fair hearing if the appellant fails to appear for the fair hearing on the established date without good cause as determined by the administrative law judge.

Program’s Response. In responding to timely filed requests for a fair hearing, the Office of Administrative Hearings:

(1)

May respond to a series of individual requests for hearing by conducting a single group hearing;

(2)

May consolidate hearings only in cases in which the sole issue involved is one of federal or State law or policy; and

(3)

Shall permit each applicant to present the appellant’s own case or be represented by the appellant’s authorized representative.

Regulation .06 Prehearing Procedures.Link Copy Citation

A hearing summary shall be prepared containing pertinent information detailing the specific action that is the basis for the appeal. The summary shall be forwarded to the appellant or the appellant’s authorized representative and to the Office of Administrative Hearings at least 6 days before the hearing date.

The appellant and the Exchange may request the names of all witnesses that the other party intends to call at the fair hearing.

Regulation .07 Hearing Procedures.Link Copy Citation

The appellant and the Exchange shall have the opportunity to:

(1)

Present witnesses;

(2)

Present documentary evidence;

(3)

Present oral and written argument without undue interference;

(4)

Establish all facts and circumstances the administrative law judge judges to be relevant; and

(5)

Question or refute any testimony or evidence, including an opportunity to confront and cross-examine all witnesses the administrative law judge judges to be adverse.

All parties that wish to call a witness at the hearing shall subpoena the witness in accordance with Office of Administrative Hearings procedures in COMAR 28.02.01.14. The appellant or authorized representative may subpoena any employee of the Exchange whose action is being contested by the appellant or whose testimony may be relevant to the issues under consideration as determined by the administrative law judge.

Right to Review Record.

(1)

If the Exchange introduces as evidence documents from the case record, special investigation file, or other sources, the appellant shall have the opportunity to examine the:

(a)

Persons who prepared the documents; and

(b)

Case record or special investigation file for the purpose of discovering information favorable to the appellant’s case.

(2)

The Exchange shall have access to relevant portions of the appellant’s medical record in accordance with Health-General Article, 4-305, Annotated Code of Maryland, to the extent required by law.

To the extent required by law, when a hearing involves a medical issue, such as a diagnosis, an examining physician’s report, or a medical review team’s decision, an additional medical assessment of the appellant’s condition shall be obtained and made part of the record if the administrative law judge considers it necessary. Any additional medical assessment shall be made by a person other than the person who made the original medical assessment and shall be obtained at the Exchange’s expense.

Regulation .08 The Record.Link Copy Citation

A verbatim recording of the fair hearing shall be made. Nonrecorded or confidential information, which the appellant does not have an opportunity to hear or see, may not be made a part of the hearing record. One transcribed copy of the recording shall be supplied to the appellant at no cost if the appellant takes a further appeal.

The following shall constitute the exclusive record of the hearing:

(1)

The transcript or recording of testimony and exhibits, or an official report containing the substance of what happened at the hearing;

(2)

All papers and requests, including those maintained electronically, filed in the proceeding; and

(3)

The administrative law judge’s decision.

The recording of testimony shall remain in the custody of the Office of Administrative Hearings for a period not to exceed 2 years, or until all litigation involving the decision is terminated. All other components of the record shall remain in the custody of the Exchange for a period not to exceed 2 years, or until all litigation involving the decision is terminated.

Regulation .09 Findings, Timing of Decision, and Effect of Decision.Link Copy Citation

Findings.

(1)

The administrative law judge shall:

(a)

Prepare a written summary of findings and conclusions based exclusively on the record; and

(b)

Make a decision based on his findings and conclusions.

(2)

The summary of findings and conclusions shall:

(a)

State the evidence, policies, regulations, or laws upon which the administrative law judge’s decision is based; and

(b)

Provide written notice to the appellant that, if they are not satisfied with the decision, they may seek additional appeals as specified in §C of this regulation.

Timing of Hearing Decision.

(1)

The administrative law judge shall forward to the appellant, and to appellant’s authorized representative, if applicable, a copy of the findings, conclusions, and decision within 90 days from the date the appellant or appellant’s representative filed a request for a fair hearing pursuant to Regulation .05A of this chapter.

(2)

If the date of the fair hearing is postponed at the appellant’s request, the length of the postponement may not be counted as part of any of the time period specified in §B(1) of this regulation.

Appeal Rights.

(1)

Any party may seek judicial review as provided in State Government Article, §10-222, Annotated Code of Maryland.

(2)

An administrative law judge’s decision:

(a)

Related to Program benefits:

(i)

Shall be implemented immediately, if adverse to the appellant.

(ii)

If favorable to the appellant, shall be implemented retroactively to the date the incorrect action was taken; or

(b)

Related to eligibility for enrollment in a qualified health plan, advance payments of the premium tax credit, cost-sharing reductions, or State-based subsidies shall be implemented in accordance with 45 CFR §155.545(c)(1).

(3)

To the extent an administrative law judge’s decision upholds the determination or redetermination of the Exchange with respect to an applicant for eligibility for enrollment in a qualified health plan or for an insurance affordability program described in Regulation .02B(10)(d) or (e), the applicant may appeal to the United States Department of Health and Human Services pursuant to 45 CFR §155.520(c).

Effect of Decision.

(1)

When the decision requires action by the Department, the Exchange shall notify the Department.

(2)

When the decision is favorable to the appellant, or when the Exchange grants the appellant the relief the appellant requests before the decision, the Exchange, where applicable, shall authorize corrected payments or relief retroactive to the date the incorrect action was taken and redetermine eligibility for household members whose eligibility may be affected by the appeals decision.

(3)

Any payment or action by the Exchange under §D(2) of this regulation may not constitute a waiver of the Exchange’s sovereign immunity from suit.

Regulation .10 Confidentiality.Link Copy Citation

If the appellant waives in writing his privilege of confidentiality as to the fair hearing, the administrative law judge shall permit members of the public to attend the hearing.

The administrative law judge may cause the removal of any member of the public whose conduct impedes the orderly progress of the hearing, or recess the hearing until it may proceed in orderly fashion.

The administrative law judge may exclude from the hearing individuals who have not given the Exchange advance notice of their intention to attend if the size of the hearing room is too small to accommodate them.

Regulation .11 Program Benefits During Appeals Process.Link Copy Citation

Benefits Pending Outcome of the Hearing.

(1)

The Program may terminate or reduce services effective as of the date specified in the notice if the Program timely mails the notice as required under Regulation .04 of this chapter and:

(a)

The appellant or the appellant’s authorized representative does not timely request a hearing in accordance with Regulation .05 of this chapter; or

(b)

The appellant or the appellant’s authorized representative withdraws in writing or abandons a request for a fair hearing.

(2)

Except as provided in §A(3) of this regulation, the Program may not terminate or reduce services until a decision is rendered after the hearing if:

(a)

The Program timely mails the notice as required under Regulation .04 of this chapter; and

(b)

The appellant requests a hearing before the date of the action.

(3)

The Program may terminate or reduce services before an administrative law judge renders a decision after a hearing if:

(a)

The administrative law judge determines at the hearing that the sole issue is one of federal or State law or policy, or the request for a fair hearing is withdrawn in writing or abandoned; and

(b)

The Program includes in the notification required by Regulation .04 of this chapter that services are to be terminated or reduced pending the hearing decision.

Reinstating Benefits.

(1)

If the Program terminates or reduces services pursuant to §A of this regulation, the Program may reinstate services if a Program recipient requests a hearing not more than 10 days after the date of action.

(2)

The reinstated services shall continue until a hearing decision, unless, at the hearing, the administrative law judge determines that the sole issue is one of federal or State law or policy.

(3)

The Program shall reinstate and continue services until a decision is rendered after a hearing if:

(a)

Action is taken without the advance notice being given to the recipient as required by Regulation .04 of this chapter;

(b)

The recipient requests a hearing within 10 days of the mailing of the notice of action; and

(c)

The Program determines that the action resulted from other than the application of federal or State law or policy.

(4)

If a recipient’s whereabouts are unknown, as indicated by the return of unforwardable Program mail directed to the recipient, any discontinued services shall be reinstated if the recipient’s whereabouts become known during the time the recipient is eligible for services.

(5)

The administrative law judge may provide for an additional period during which time the request for a fair hearing will result in reinstatement of a recipient’s assistance to be continued until the hearing decision.

Regulation .12 Eligibility for Enrollment in a Qualified Health Plan, for Advance Payments of Premium Tax Credit, for Cost-Sharing Reductions, and for the State-Based Young Adult Health Insurance Subsidies Program Pending Appeal.Link Copy Citation

Eligibility for Enrollment in a Qualified Health Plan.

(1)

If, upon initial determination, an applicant has been determined to be ineligible to enroll in a qualified health plan, the applicant may not enroll in a qualified health plan pending the outcome of the appeal.

(2)

Except where the applicant does not appeal a redetermination of eligibility within 90 days of such redetermination, an applicant enrolled in a qualified health plan who, upon redetermination, is found ineligible to remain enrolled in the qualified health plan may remain enrolled in the qualified health plan pending the outcome of the appeal.

Eligibility for Advance Payments of the Premium Tax Credit, Cost-Sharing Reduction, and/or the State-Based Young Adult Health Insurance Subsidies Program.

(1)

Except where the applicant does not appeal an initial determination of eligibility within 90 days of such determination, an applicant who, upon initial determination, has been determined to be eligible to enroll in a qualified health plan may enroll in a qualified health plan within 90 days of the determination of eligibility for a qualified health plan notwithstanding ineligibility for or the amount of Advance Payments of the Premium Tax Credit, Cost-Sharing Reduction, or State-based subsidy for which the applicant was determined to be eligible.

(2)

Pending the outcome of the appeal, the applicant under §B(1) of this regulation will receive only the amount of the advance payments of the premium tax credit, cost-sharing reduction, and/or State-based subsidy if any, for which applicant was determined to be eligible upon initial determination.

(3)

Except where the applicant does not appeal a redetermination of eligibility within 90 days of such redetermination, an applicant who is receiving advance payments of the premium tax credit and/or cost-sharing reduction and is found to be ineligible for, or subject to a reduced amount of, advance payments of the premium tax credit and/or cost-sharing reduction during a redetermination may elect to continue to receive the advance payments of the premium tax credit and/or cost-sharing reduction that the applicant had been receiving immediately prior to the redetermination pending the outcome of the appeals process, provided that the applicant attests to understanding that by continuing to receive the advance payments of the premium tax credit the applicant may incur a liability to the Internal Revenue Service pursuant to 26 U.S.C. §36B.

Regulation .13 Applicability of Regulations.Link Copy Citation

If a conflict exists between this chapter and the Rules of Procedure of the Office of Administrative Hearings in COMAR 28.02.01, this chapter shall govern.

Regulation .14 Authorized Representatives.Link Copy Citation

Definitions.

(1)

“Authorized representative” means an individual or organization acting responsibly on behalf of the applicant in accordance with this regulation, in assisting with an applicant’s application, renewal of eligibility, appeals, and other ongoing communications with the Exchange.

(2)

“Signature” includes electronic, including telephonically recorded, signatures and handwritten signatures transmitted by facsimile or other electronic transmissions.

Designating an Authorized Representative.

(1)

An applicant may designate any individual or organization to serve as authorized representative.

(2)

An authorized representative may be designated either:

(a)

In writing, including the applicant’s signature; or

(b)

By providing proof of legal authority to act on behalf of an applicant.

(3)

Legal authority includes, but is not limited to the:

(a)

Applicant’s parent, if the applicant is a minor;

(b)

Applicant’s legal guardian, if one has been appointed, or a person who has in good faith filed an application to be appointed the applicant’s legal guardian but who has not yet been appointed the applicant’s legal guardian;

(c)

Applicant’s healthcare surrogate as defined in Health-General Article, §5-605, Annotated Code of Maryland;

(d)

Personal representative of applicant’s estate, or a person who has in good faith filed an application to be appointed the personal representative of the applicant’s estate but who has not yet been appointed the personal representative of the applicant’s estate;

(e)

Individual appointed to make legal or medical decisions on behalf of the applicant pursuant to a validly executed power of attorney; or

(f)

Attorney or paralegal retained by the applicant.

(4)

For individuals who lack the capacity to designate an authorized representative and for whom no other individual or organization has the legal authority to act under §B(2) of this regulation, an authorized representative can be any individual or organization acting responsibly on behalf of the applicant who:

(a)

In good faith, is acting in the best interest of the applicant; and

(b)

Declares the applicant lacks legal capacity, and for organizations, declares that its directors, employees, officers or employers, if any, do not have a direct financial interest in the outcome of the fair hearing.

(5)

For individuals who lack the capacity to designate an authorized representative, for whom no other individual or organization has the legal authority to act under §B(2) of this regulation, and on behalf of whom no individual or organization covered by §B(4) of this regulation is willing and able to act, an authorized representative can be any individual or organization with a direct financial interest in the outcome of the hearing or whose employer has a direct financial interest in the outcome of the hearing who:

(a)

In good faith is acting in the best interest of the applicant;

(b)

Declares that the applicant lacks legal capacity; and

(c)

Declares that to the best of the authorized representative’s belief, no other individual or organization is willing and able to act on the applicant’s behalf.

Time for Authorization. Designation of an authorized representative, or the declarations by an individual or organization required under §B(4) or (5) of this regulation to become an authorized representative, can take place at any time, including, but not limited to, the time of application, upon redetermination, upon filing an appeal, and at the appeal hearing.

Duration of Representation. The power to act as an authorized representative is valid until the applicant modifies the authorization or notifies the Exchange that the representative is no longer authorized to act on his or her behalf, there is a change in the legal authority upon which the individual or organization’s authority was based, or the authorized representative informs the Exchange, as required by 45 CFR §155.227(d)(2), that the representative no longer has legal authority to act on behalf of the applicant. Such notice shall be in writing and shall include the applicant’s signature or the authorized representative’s signature, as appropriate.

Powers of Authorized Representative. Authorized representatives may be authorized to perform all, or fewer than all, of the following:

(1)

Sign an application on the applicant’s behalf;

(2)

Complete and submit an update or a renewal form or respond to a request for redetermination;

(3)

Receive copies of the applicant’s notice and other communications from the Exchange; and

(4)

Act on behalf of the applicant in all matters with the Exchange including appeals.

Obligations of Authorized Representative. An authorized representative:

(1)

Is responsible for fulfilling all the responsibilities encompassed within the scope of the authorized representation as described in §E of this regulation to the same extent as the individual the representative represents;

(2)

Shall agree to maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant provided by the Exchange.

Authorized Representatives Through an Organization. A provider, staff member, or volunteer of an organization shall sign an agreement to adhere to the federal regulations governing authorized representatives as laid out in 42 CFR §435.923 or 45 CFR §155.227, as applicable, as well as relevant State and federal laws concerning conflicts of interest and confidentiality of information.

Chapter 12. Application Counselor Sponsoring Entity Designation Standards

Regulation .01 Scope.Link Copy Citation

In General. This chapter applies to any community-based organization, health care provider, unit of State or local government, or other entity seeking designation as an application counselor sponsoring entity by the Maryland Health Benefit Exchange.

Regulation .02 Definitions.Link Copy Citation

In this subtitle, the following terms have the meanings indicated.

Terms Defined.

(1)

“Applicant” means a community-based organization, health care provider, unit of State or local government, or other entity applying for designation as an application counselor sponsoring entity.

(2)

“Application counselor sponsoring entity” or “sponsoring entity” has the meaning set forth in Insurance Article, §31-101(a-2), Annotated Code of Maryland.

(3)

“Certified application counselor” has the meaning set forth in Insurance Article, §31-101(a-1), Annotated Code of Maryland.

(4)

“Commissioner” means the Maryland Insurance Commissioner.

(5)

“Consolidated Services Center” has the meaning set forth in Insurance Article, §31-101(c-2), Annotated Code of Maryland.

(6)

“Individual Exchange” or “Exchange” has the meaning set forth in Insurance Article, §31-101(h), Annotated Code of Maryland.

(7)

“Individual Exchange connector entity” has the meaning set forth in Insurance Article, §31-101(k), Annotated Code of Maryland.

(8)

“Individual Exchange navigator” has the meaning set forth in Insurance Article, §31-101(i), Annotated Code of Maryland.

(9)

“Maryland Health Benefit Exchange” has the meaning set forth in Insurance Article, §31-101(e), Annotated Code of Maryland.

Regulation .03 Eligibility Requirements.Link Copy Citation

To be eligible for designation as an application counselor sponsoring entity, an applicant shall:

Complete and submit to the Maryland Health Benefit Exchange the application counselor sponsoring entity application set forth under Regulation .05 of this chapter;

Agree to comply with the requirements set forth in the application counselor sponsoring entity application, including the requirements for oversight of its certified application counselors;

Comply with any applicable requirements of the Maryland Department of Health and the Commissioner; and

Enter into a formal written agreement with all employed or engaged certified application counselors whereby certified application counselors agree to comply with the provisions of the application counselor training and certification standards under COMAR 14.35.13 and 45 CFR §155.225.

Regulation .04 Scope of Authority.Link Copy Citation

A designated application counselor sponsoring entity may employ or engage certified application counselors to:

(1)

Provide information to consumers about the full range of qualified health plan and qualified dental plan options and insurance affordability programs, including advance premium tax credits and cost-sharing subsidies, the Maryland Medical Assistance Program, and the Maryland Children’s Health Program, for which they are eligible;

(2)

Assist consumers with the application process for determining eligibility for insurance affordability programs, including advance premium tax credits and cost-sharing subsidies, the Maryland Medical Assistance Program, and the Maryland Children’s Health Program;

(3)

Facilitate plan selection and enrollment of eligible individuals in qualified health plans, qualified dental plans, and access to advance premium tax credit and other cost-sharing subsidies; and

(4)

Provide to consumers uniform, factual, and unbiased information approved by the Maryland Medical Assistance Program about all participating managed care organizations, including report cards, lists of enhanced benefits and covered services, and participating providers.

A designated application counselor sponsoring entity may not permit certified application counselors to:

(1)

Enroll Maryland Medical Assistance Program/Maryland Children’s Health Program eligible individuals into managed care organizations; or

(2)

Express a personal or professional assessment about which Maryland Medical Assistance Program/Maryland Children’s Health Program managed care organization may be most appropriate for an eligible individual, may not make a managed care organization selection on the applicant’s behalf, and may not otherwise counsel an applicant about the selection of a managed care organization.

If a Maryland Medical Assistance Program/Maryland Children’s Health Program eligible consumer seeks further counseling or additional assistance in choosing a managed care organization, a designated application counselor sponsoring entity shall instruct the certified application counselor to refer the consumer to the Consolidated Services Center or to a local agency caseworker.

An Individual Exchange connector entity may also be a designated application counselor sponsoring entity only under the following conditions:

(1)

No agent, employee, or volunteer of the Individual Exchange connector entity may hold more than a single certification as either an Individual Exchange navigator or a certified application counselor;

(2)

All Individual Exchange connector entity grant funds must be wholly segregated from certified application counselor program funding, if applicable;

(3)

No certified application counselor may be compensated in whole or in part from Individual Exchange connector entity grant funding, and no Individual Exchange navigator may be compensated in whole or in part from application counselor program funding, if applicable; and

(4)

All utilities, computer systems, and other components of operations which are utilized jointly by both the Individual Exchange connector and application counselor programs, including executive and administrative staff, shall be cost allocated as directed by the Maryland Health Benefit Exchange and Maryland Department of Health in relation to the percentage of consumers served by the entity who are determined eligible for Maryland Medical Assistance Program/Maryland Children’s Health Program, advance premium tax credits, or cost-sharing subsidies, and who are enrolled in qualified health plans and managed care organizations.

Regulation .05 Application Procedures.Link Copy Citation

In order to obtain an application counselor sponsoring entity designation, the applicant shall submit to the Maryland Health Benefit Exchange:

(1)

An application on the form approved by the Maryland Health Benefit Exchange in consultation with the Commissioner and the Maryland Department of Health;

(2)

An attestation that the applicant will notify the Maryland Health Benefit Exchange of any changes in information the applicant provides or to which the applicant attests on the application form within 30 days of such change;

(3)

An attestation that the applicant will not impose a fee on individuals for services provided by certified application counselors employed or engaged by the applicant;

(4)

An attestation that the applicant will disclose to the Maryland Health Benefit Exchange and to individuals to whom certified application counselors employed or engaged by the applicant provide services any relationships it has with a carrier, an insurance producer, or a third-party administrator or a managed care organization that participates in the Maryland Medical Assistance Program/Maryland Children’s Health Program;

(5)

An attestation that the applicant will act in the best interest of the individuals for whom the certified application counselors employed or engaged by the applicant are authorized to provided services;

(6)

An attestation that the applicant will not receive compensation from a carrier, insurance producer, managed care organization, or a third-party administrator for application counselor services provided by certified application counselors employed or engaged by the applicant;

(7)

An attestation that the applicant will compensate employed or engaged certified application counselors in the manner approved by the Maryland Health Benefit Exchange working in consultation with the Commissioner and the Maryland Department of Health;

(8)

An attestation that the applicant will not directly or through employed or engaged certified application counselors provide monetary or other financial incentives to individuals to apply for health insurance coverage through Maryland Health Connection;

(9)

An attestation that the applicant will not receive compensation from the Maryland Health Benefit Exchange for certified application counselor services;

(10)

An attestation that the applicant will monitor the performance of its certified application counselors in accordance with the requirements set forth by the Maryland Health Benefit Exchange;

(11)

An attestation that the applicant will enforce the required agreement set forth under Regulation .03D of this chapter;

(12)

An attestation that the applicant will oversee employed or engaged certified application counselors pursuant to the oversight plan approved by the Maryland Health Benefit Exchange, in consultation with the Commissioner and the Maryland Department of Health;

(13)

An attestation that the applicant will comply with all applicable federal and State privacy and security standards, and will ensure that its certified application counselors also comply with these standards;

(14)

An attestation that the applicant will operate within its scope of authority and ensure that it and its certified application counselors comply with the requirements set forth under Regulation .04 of this chapter;

(15)

An attestation that the applicant will comply with any applicable requirements of the Maryland Department of Health and the Commissioner; and

(16)

An application fee to the extent permitted by law and in the manner specified by the Maryland Health Benefit Exchange, if applicable.

The Maryland Health Benefit Exchange may not consider an application to be complete until it has received all required materials.

If the application is not completed with all required materials within 45 days after the Maryland Health Benefit Exchange receives the signed application form, the Maryland Health Benefit Exchange may consider the application withdrawn.

The Maryland Health Benefit Exchange shall approve or deny an application within 45 days after its completion and receipt of all required materials.

Approval of an application will be contingent on the applicant’s execution of a designation agreement, in the form presented by the Maryland Health Benefit Exchange working in consultation with the Commissioner and the Maryland Department of Health.

The Maryland Health Benefit Exchange may exercise its discretion in approving an application and designating an entity as an application counselor sponsoring entity, taking into consideration:

(1)

The applicant’s ability to satisfy the requirements set forth in the application; and

(2)

The resources, oversight capacity, and needs of the Maryland Health Benefit Exchange, the Connector Program, the Maryland Insurance Administration, the Maryland Department of Health, and other outreach and enrollment efforts.

Regulation .06 Designation Term and Renewal.Link Copy Citation

Term. An application counselor sponsoring entity designation expires 2 years after the date it is issued unless it is renewed or revoked prior to that time.

Renewal.

(1)

Notice.

(a)

At least 60 days before the expiration of an application counselor sponsoring entity designation, the Maryland Health Benefit Exchange shall notify the application counselor sponsoring entity directly at the entity’s address on file, including email address, with the Maryland Health Benefit Exchange, of the expiration date of an application counselor sponsoring entity designation.

(b)

The notification shall include:

(i)

A renewal application;

(ii)

The date by which the Maryland Health Benefit Exchange must receive the renewal application for the renewal to be issued before the designation expires; and

(iii)

The amount of any renewal fee.

(2)

Eligibility for Renewal. An application counselor sponsoring entity designation may be renewed for an additional 2-year term if the holder:

(a)

Is otherwise entitled to receive application counselor sponsoring entity designation, in accordance with the eligibility requirements set forth under Regulation .03 of this chapter;

(b)

Files a timely renewal application on the form approved by the Maryland Health Benefit Exchange, either by mail or electronically; and

(c)

Pays to the Maryland Health Benefit Exchange a renewal fee to the extent permitted by law and in the manner specified by the Maryland Health Benefit Exchange.

Regulation .07 Revocation of Designation.Link Copy Citation

The Maryland Health Benefit Exchange, in consultation with the Commissioner and Maryland Department of Health, shall revoke an application counselor sponsoring entity designation for any failure to act in accordance with the application counselor sponsoring entity attestations set forth under Regulation .05A of this chapter pursuant to the procedures for withdrawal or revocation set forth under the agreement between the Maryland Health Benefit Exchange and the application counselor sponsoring entity.

Chapter 13. Application Counselor Training and Certification Standards

Regulation .01 Scope.Link Copy Citation

This chapter sets forth the qualifications, training, and certification standards for an agent, employee, or volunteer of an application counselor sponsoring entity who applies to receive an application counselor certification and is required under Insurance Article, §31-113(r)(1)(ii), Annotated Code of Maryland, to hold an application counselor certification to provide the services set forth below.

Regulation .02 Definitions.Link Copy Citation

In this subtitle, the following terms have the meanings indicated.

Terms Defined.

(1)

“Applicant” means a community-based organization, health care provider, unit of State or local government, or other entity applying for designation as an application counselor sponsoring entity.

(2)

“Application counselor sponsoring entity” or “sponsoring entity” has the meaning set forth in Insurance Article, §31-101(a-2), Annotated Code of Maryland.

(3)

“Certified application counselor” has the meaning set forth in Insurance Article, §31-101(a-1), Annotated Code of Maryland.

(4)

“Commissioner” means the Maryland Insurance Commissioner.

(5)

“Consolidated Services Center” has the meaning set forth in Insurance Article, §31-101(c-2), Annotated Code of Maryland.

(6)

“Individual Exchange connector entity” has the meaning set forth in Insurance Article, §31-101(k), Annotated Code of Maryland.

(7)

“Individual Exchange navigator” has the meaning set forth in Insurance Article, §31-101(i), Annotated Code of Maryland.

(8)

“Insurance affordability programs” has the meaning set forth in 42 CFR §435.4.

(9)

“Maryland Health Benefit Exchange” has the meaning set forth in Insurance Article, §31-101(e), Annotated Code of Maryland.

Regulation .03 Eligibility Requirements.Link Copy Citation

To qualify for an application counselor certification, an applicant shall:

Be of good character and trustworthy;

Be at least 18 years old;

Be an agent, employee, or volunteer of an application counselor sponsoring entity;

Not be an Individual Exchange navigator;

Enter into a formal written agreement with an application counselor sponsoring entity agreeing to comply with the provisions of this chapter and 45 CFR §155.225;

Successfully complete and comply with any ongoing requirements of the training program set forth under Regulation .06 of this chapter;

Complete and submit to the Maryland Health Benefit Exchange an application counselor application set forth under Regulation .05 of this chapter;

Agree to comply with the requirements set forth in the application counselor application; and

Comply with any applicable requirements of the Maryland Department of Health and the Commissioner.

Regulation .04 Scope of Authority.Link Copy Citation

A certified application counselor may:

(1)

(2)

(3)

Facilitate plan selection and enrollment of eligible individuals in qualified health plans, qualified dental plans, and access to advance premium tax credit and other cost-sharing subsidies; and

(4)

A certified application counselor may not express a personal or professional assessment about which Maryland Medical Assistance Program/Maryland Children’s Health Program managed care organization may be most appropriate for an eligible individual, may not make a managed care organization selection on the applicant’s behalf, and may not otherwise counsel an applicant about the selection of a managed care organization.

If a Maryland Medical Assistance Program/Maryland Children’s Health Program eligible consumer seeks further counseling or additional assistance in choosing a managed care organization, a certified application counselor shall refer the consumer to the Consolidated Services Center or a local agency caseworker.

A certified application counselor may not concurrently hold an Individual Exchange navigator certification.

Regulation .05 Application Procedures.Link Copy Citation

In order to obtain an application counselor certification, the applicant shall submit to the Maryland Health Benefit Exchange:

(1)

An application, on the form approved by the Maryland Health Benefit Exchange in consultation with the Commissioner and the Maryland Department of Health;

(2)

An attestation that the applicant will notify the Maryland Health Benefit Exchange of any changes to information that the applicant provides or to which the applicant attests on the application form within 30 days of such change;

(3)

An attestation that the applicant will not impose a fee on individuals to whom the applicant provides services;

(4)

An attestation that the applicant will disclose to the Maryland Health Benefit Exchange, the application counselor sponsoring entity, and individuals to whom the applicant provides services any relationships the applicant has with a carrier, an insurance producer, a third-party administrator, or a managed care organization that participates in the Maryland Medical Assistance Program/Maryland Children’s Health Program, as well as other potential conflicts of interest;

(5)

An attestation that the applicant will act in the best interest of the individuals for whom the applicant is authorized to provide services;

(6)

An attestation that the applicant will not receive compensation from a carrier, insurance producer, managed care organization or third-party administrator for application counselor services;

(7)

An attestation that the applicant will not receive compensation from the Maryland Health Benefit Exchange;

(8)

An attestation that the applicant will accept compensation for application counselor-related duties only from its application counselor sponsoring entity, as approved by the Maryland Health Benefit Exchange in consultation with the Commissioner and the Maryland Department of Health;

(9)

An attestation that the applicant will not provide monetary or other financial incentives to individuals to apply for health insurance coverage through Maryland Health Connection;

(10)

An attestation that the applicant will comply with the oversight plan adopted by its application counselor sponsoring entity approved by the Maryland Health Benefit Exchange, in consultation with the Commissioner and the Maryland Department of Health;

(11)

An attestation that the applicant will comply with all State requirements, restrictions, and conflict of interest rules applicable to Individual Exchange navigators;

(12)

An attestation that the applicant will comply with the required agreement set forth under Regulation .03A(5) of this chapter;

(13)

An attestation that the applicant will comply with all applicable federal and State privacy and security standards;

(14)

An attestation that the applicant will operate within the applicant’s scope of authority and ensure that he or she complies with the requirements set forth under Regulation .04 of this chapter;

(15)

An attestation that the applicant will comply with any applicable requirements of the Maryland Department of Health and the Commissioner;

(16)

An application fee if permitted by law and in the manner specified by the Maryland Health Benefit Exchange; and

(17)

Evidence that the applicant has successfully completed the Maryland Health Benefit Exchange application counselor certification training program specified under COMAR 14.35.02.04A and passed the examination specified under COMAR 14.35.02.04D.

The Exchange may not consider an application to be complete until it has received all required materials.

Regulation .06 Training Requirements.Link Copy Citation

In order to obtain application counselor certification, an individual shall meet the training and examination requirements specified under COMAR 14.35.02.04.

Regulation .07 Term.Link Copy Citation

An application counselor certification expires 2 years after the date it is issued unless it is renewed.

Regulation .08 Renewal.Link Copy Citation

Notice.

(1)

At least 60 days before the expiration of an application counselor certification, the Maryland Health Benefit Exchange shall notify the application counselor using the address on file, including email address, with the Maryland Health Benefit Exchange, of the expiration date of an application counselor certification.

(2)

The notification shall include:

(a)

A renewal application;

(b)

The date by which the Maryland Health Benefit Exchange must receive the renewal application for the renewal to be issued before the certification expires; and

(c)

The amount of any renewal fee.

Eligibility for Renewal. An application counselor certification may be renewed for an additional 2-year term if the holder:

(1)

Is otherwise entitled to receive application counselor certification, in accordance with the eligibility requirements set forth under Regulation .03 of this chapter;

(2)

Files a timely renewal application on the form approved by the Maryland Health Benefit Exchange, either by mail or electronically;

(3)

Pays to the Maryland Health Benefit Exchange a renewal fee to the extent permitted by law and in the manner specified by the Maryland Health Benefit Exchange; and

(4)

Has completed the education requirements set forth under COMAR 14.35.03.02B(4), 14.35.03.02C, and 14.35.03.02D, where determined to be applicable by the Maryland Health Benefit Exchange.

Regulation .09 Suspension or Revocation.Link Copy Citation

The Commissioner may suspend or revoke an application counselor certification for any reason set forth under Insurance Article, §31-113(l)(1), Annotated Code of Maryland, made applicable to application counselors pursuant to Insurance Article, §31-113(r), Annotated Code of Maryland, or for any reason set forth under 45 CFR §155.225.

An application counselor’s certification is automatically suspended if his or her application counselor sponsoring entity’s designation expires or is withdrawn by the Maryland Health Benefit Exchange.

An application counselor’s certification that has been suspended under §B of this regulation may be reinstated if the application counselor becomes an agent, employee, or volunteer of another application counselor sponsoring entity with a valid designation and executes the agreement required under Regulation .03A(5) of this chapter.

Chapter 14. Termination, Cancellation, and Rescission of Qualified Health Plan

Regulation .01 Scope.Link Copy Citation

This chapter describes the events that may result in the termination, cancellation, or rescission of the enrollment of an individual enrolled in a QHP through the Individual Exchange.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

“Cancellation” means an action that ends a qualified individual's enrollment through the Exchange on the date such enrollment became effective resulting in enrollment through the Exchange never having been effective.

(2)

“Product” has the meaning stated in Insurance Article, §15-1309(a)(3)(i), Annotated Code of Maryland.

(3)

“Reinstatement” means a correction of an erroneous termination or cancellation action that results in restoration of an enrollment with no break in coverage.

(4)

“Same QHP policy” means that one enrollee is enrolled under the same QHP contract as another enrollee.

(5)

“Termination” means an action taken after a coverage effective date that ends an enrollee's enrollment through the Exchange for a date after the original coverage effective date resulting in a period during which the individual was enrolled in coverage through the Exchange.

Regulation .03 Terminations in General.Link Copy Citation

An enrollee who is the contract holder of a QHP who terminates enrollment in a QHP also terminates the enrollment of the other enrollees in the household.

Each enrollee, who is not the contract holder, may terminate enrollment in a QHP without affecting the enrollment status of the enrollee’s household or each individual member of the enrollee’s household other than the enrollee.

A carrier shall process a request from the contract holder of a QHP to terminate coverage under Regulation .04 of this chapter for all enrollees promptly and without undue delay.

A carrier shall process the Exchange’s termination determination under Regulation .06 of this chapter promptly and without undue delay.

A carrier shall maintain records of termination of enrollment in a QHP in the format specified by the Exchange in an electronic data interchange format for a period of 10 years.

A carrier shall make reasonable accommodations for all individuals with disabilities (as defined by the Americans with Disabilities Act), including head-of-household and non-head-of-household enrollees, before terminating the individual's enrollment.

A carrier shall send an electronic transaction to the Exchange documenting, or acknowledging, each termination of coverage carried out under this chapter, promptly and without undue delay.

In cases of retroactive termination dates, the carrier shall accept the Exchange’s adjusted calculations of APTC, and premiums and changes to the plan variation of the QHP.

A carrier shall confirm the termination of an enrollee’s coverage with a notice provided to the contract holder indicating the enrollees affected by the termination and the effective date of the termination.

Regulation .04 Enrollee-Initiated Terminations — In General.Link Copy Citation

An enrollee may terminate the enrollee’s coverage in a QHP at any time within a month for a termination effective at the end of the month.

An enrollee may request a termination of the enrollee’s coverage in a QHP by providing notice to the Exchange or the enrollee’s QHP carrier as follows:

(1)

Enrollees seeking to terminate coverage for an enrollee or enrollees on a QHP shall provide notice to the Exchange; and

(2)

Enrollees seeking to terminate coverage for the enrollee’s household may notify either the Exchange or the QHP carrier.

Date of Terminations. If the enrollee provides notice to the Exchange or the carrier on any day within the month, the date of termination is the end of the month.

If an enrollee terminates coverage in one QHP because the enrollee elects enrollment in a different QHP, coverage in the original qualified health plan ends at midnight the day before the effective date of coverage in the enrollee’s new QHP.

Death.

(1)

In the case of a termination due to death, the last day of enrollment in a QHP through the Exchange is the date of death.

(2)

Any applicable premium refund, or premium due, shall be processed by the deceased enrollee's QHP in accordance with State law.

(3)

Notice of the enrollee’s death may be provided to the Exchange or the deceased enrollee’s QHP by:

(a)

The policyholder under COMAR 31.10.01.02B(7), or subscriber under COMAR 31.12.02.02B(11), of the deceased enrollee’s QHP;

(b)

An enrollee who is 18 years or older and enrolled in the same QHP policy of the deceased enrollee; or

(c)

The authorized representative of an enrollee under COMAR 14.35.11.14.

Retroactive Terminations.

(1)

An enrollee may retroactively terminate or cancel the enrollee's coverage or enrollment in a QHP when the enrollee:

(a)

Demonstrates to the Exchange that the enrollee enrolled in Medicare Part A or B coverage with a retroactive effective date; and

(b)

Requests retroactive termination of QHP coverage within 60 days of the enrollment.

(2)

The effective date of the retroactive termination must be no earlier than the later of the day before the first day of coverage under Medicare Part A or B, and the day that is 6 months before the retroactive termination in QHP coverage is requested.

(3)

A retroactive termination date as described in this section is not available for enrollments in stand-alone dental plans.

Regulation .05 Enrollee-Initiated Terminations — Due to Error, Misconduct, or Enrollment without Knowledge or Consent.Link Copy Citation

An enrollee may retroactively terminate the enrollee’s coverage when:

(1)

The enrollee attempted to terminate the enrollee’s coverage and the enrollee experienced a technical error that did not allow the enrollee to terminate the enrollee’s coverage;

(2)

The enrollee’s enrollment in a QHP through the Exchange was unintentional, inadvertent, or erroneous and was the result of the error or misconduct of an officer, employee, or agent of the Exchange, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities; or

(3)

The enrollee was enrolled in a QHP without the enrollee’s knowledge or consent by any third party, including third parties who have no connection with the Exchange.

Misconduct under §A(2) of this regulation means the failure of an officer, employee, or agent of the Exchange, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities to comply with applicable standards under COMAR 14.35.14 or other applicable State or federal laws as determined by the Exchange.

Except as specified in §D of this regulation, the enrollee shall request termination under §A of this regulation by notifying the Exchange of the request:

(1)

Within 60 days of discovering the technical error under §A(1) of this regulation;

(2)

Within 60 days of discovering the unintentional, inadvertent, or erroneous enrollment under §A(2) of this regulation; or

(3)

Within 60 days of discovering the enrollment under §A(3) of this regulation.

If the enrollee discovers an enrollment under §A of this regulation in the previous calendar year, the enrollee shall request termination under §A of this regulation by notifying the Exchange of the request by the end of March the calendar year immediately following the calendar year with the enrollment under §A of this regulation.

Notification to the Exchange under §§C and D of this regulation shall be satisfied if the enrollee provides notice:

(1)

To an Exchange-certified navigator, an Exchange-authorized broker, or an Exchange-certified consolidated service center representative; and

(2)

Using any of the methods of communication listed under COMAR 14.35.07.03B.

The effective date of the termination under §A of this regulation shall be:

(1)

For a retroactive termination under §A(1) of this regulation, no later than the end of the month when the enrollee contacted the Exchange to request termination of the enrollee’s enrollment through the Exchange; and

(2)

For a retroactive termination under §A(2) or (3) of this regulation:

(a)

The original coverage effective date; or

(b)

A later date, as determined appropriate by the Exchange, based on the circumstances of the termination.

Regulation .06 Termination by the Exchange.Link Copy Citation

A carrier shall terminate an enrollee’s coverage in a qualified health plan upon receiving an electronic data transaction from the Exchange directing that the enrollee’s coverage be terminated.

The Exchange shall direct the carrier to terminate an enrollee’s enrollment in a QHP if:

(1)

The enrollee is no longer eligible for coverage in a QHP through the Exchange;

(2)

The enrollee requests termination under Regulations .04 and .05 of this chapter;

(3)

The enrollee’s coverage is rescinded under 45 CFR §147.128;

(4)

The QHP terminates or is decertified under 45 CFR §155.1080;

(5)

The Exchange determines that:

(a)

An enrollee was enrolled in a QHP without the enrollee’s knowledge or consent by a third party, including by a third party with no connection with the Exchange; and

(b)

Where possible, the Exchange has provided reasonable notice to the enrollee of the Exchange’s determination;

(6)

The enrollee changes from one QHP to another QHP during an annual open enrollment period under COMAR 14.35.07.11A(1) or a special enrollment period under COMAR 14.35.07.12—.19; and

(7)

The enrollee moves outside of the service area under 45 CFR §155.430(b)(2)(vii) in reference to 45 CFR §147.106(b)(5).

If the enrollee becomes eligible for other minimum essential coverage but does not request termination in accordance with Regulation .04 of this chapter at the time of plan renewal, the enrollee may choose to remain enrolled in a QHP without the provision of financial assistance through APTC or CSR payments.

If the enrollee does not choose to remain enrolled in the QHP through the Exchange when the enrollee becomes eligible for other minimum essential health coverage under §C of this regulation, the Exchange shall initiate termination of the enrollee’s coverage upon completion of the redetermination process specified in 45 CFR §155.330.

Upon termination by the Exchange, the last day of coverage by a QHP is:

(1)

The last day of the enrollee’s eligibility, if the Exchange determines an enrollee to be no longer eligible for coverage in a QHP through the Individual Exchange;

(2)

The last day of the coverage month in which coverage is rescinded, if the enrollee’s coverage is rescinded in accordance with 45 CFR §147.128;

(3)

The last day of the coverage month in which the QHP is terminated or decertified, if the QHP terminates or, as described in 45 CFR §155.1080, is decertified;

(4)

The last day of the coverage month in which the enrollee is determined newly eligible for enrollment in Medicaid or MCHP, if the enrollee chooses to terminate the QHP;

(5)

The day before the first day of enrollment in the new QHP if an enrollee terminates coverage in a previous QHP and selects a new QHP during an annual open enrollment period under COMAR 14.35.07.11A(1) or a special enrollment period under COMAR 14.35.07.12—.19;

(6)

The original coverage effective date for a cancellation under §B(5) of this regulation;

(7)

The date of death, if the enrollee is terminated because of the enrollee’s death; or

(8)

The day before the change in the enrollee’s circumstance if the enrollee is terminated because of a circumstance where the enrollee could not have prevented the disruption of the QHP enrollment.

For an enrollee’s dependent turning age 26, the carrier may not terminate coverage of the dependent before the end of the coverage year in which the dependent reaches age 26.

Regulation .07 Termination by Carrier.Link Copy Citation

A carrier may only terminate an individual’s coverage in a QHP before receiving an instruction from the Exchange to terminate coverage:

(1)

If the enrollee requests termination of the enrollee’s enrollment to the carrier, and the termination follows the procedures in Regulation .04 of this chapter;

(2)

If the enrollee’s coverage is rescinded under 45 CFR §147.128;

(3)

If the carrier is decertified by the Exchange under COMAR 14.35.16.11;

(4)

If the carrier ceases to offer the QHP that an enrollee is enrolled in through the Exchange under 45 CFR §147.106(b)(4) and the carrier follows the requirements under 45 CFR §147.106(c);

(5)

If the carrier ceases to offer any QHPs through the Exchange under 45 CFR §147.106(b)(4) and the carrier follows the requirements under 45 CFR §147.106(d);

(6)

If the enrollee has performed an act or practice that constitutes fraud or intentional misrepresentation of material fact in connection with the coverage under 45 CFR §147.106(b)(2); or

(7)

For nonpayment of premiums as specified in §B of this regulation.

Termination for Nonpayment.

(1)

A carrier may terminate coverage for nonpayment of premium if the enrollee has not made applicable premium payments and at the time the enrollee first fails to pay premiums:

(a)

The enrollee is receiving APTC, and the 3-month grace period under Insurance Article, §15-1315(c)—(e), Annotated Code of Maryland, has been exhausted; or

(b)

The enrollee is not receiving APTC and all other applicable grace periods under State law have been exhausted.

(2)

A carrier may not terminate coverage for failure to make a premium payment if:

(a)

Through a renewal of the plan under 45 CFR §155.335, the enrollee maintains coverage in the same QHP or same product that is a uniform modification of coverage under Insurance Article, §15-1309(a)(4), Annotated Code of Maryland; and

(b)

The applicable grace period has not been exhausted under:

(i)

Insurance Article, §15-1315(c)—(e), Annotated Code of Maryland; or

(ii)

Another applicable grace period under State law if the enrollee is not receiving APTC.

(3)

The last day of coverage is:

(a)

The last day of the first month of the 3-month grace period when terminating an individual after exhaustion of the 3-month grace period for individuals receiving APTC; and

(b)

31 days after the missed premium payment was due when terminating an individual after the exhaustion of any other applicable grace period.

Notice of Non-Payment of Premiums. If an enrollee is delinquent on premium payment, the carrier shall provide the enrollee with notice of such payment delinquency. A carrier shall provide such notices promptly and without undue delay, within 10 business days of the date the issuer should have discovered the delinquency.

Regulation .08 Cancellation.Link Copy Citation

An individual’s enrollment in a QHP may be canceled only if:

(1)

The enrollee requests voluntary cancellation of the enrollee’s enrollment to the Exchange or the carrier under §C of this regulation;

(2)

The enrollee’s coverage is rescinded under 45 CFR §147.128; or

(3)

The enrollee does not provide the first month’s premium required to effectuate an enrollment by the due dates set forth at COMAR 14.35.07.11F.

To request cancellation of the individual’s enrollment under §A of this regulation, the individual shall notify the Exchange or the carrier of the request to cancel before or on the last day of the month prior to the date the coverage begins.

An enrollee may retroactively cancel the enrollee’s coverage if:

(1)

The enrollee attempted to cancel the enrollee’s coverage and the enrollee experienced a technical error that did not allow the enrollee to cancel the enrollee’s coverage;

(2)

(3)

The enrollee was enrolled in a QHP without the enrollee’s knowledge or consent by any third party, including third parties who have no connection with the Exchange.

Misconduct under §C(2) of this regulation means the failure of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities to comply with applicable standards under COMAR 14.35.14 or other applicable State or federal laws as determined by the Exchange.

Except as specified in §F of this regulation, the enrollee shall request cancellation under §C of this regulation by notifying the Exchange of the request:

(1)

Within 60 days after the enrollee discovered the technical error under §C(1) of this regulation;

(2)

Within 60 days of discovering the unintentional, inadvertent, or erroneous enrollment under §C(2) of this regulation; or

(3)

Within 60 days of discovering of the enrollment under §C(2) of this regulation.

If the enrollee discovers an enrollment under §C of this regulation in the previous calendar year, the enrollee shall request termination under §C of this regulation by notifying the Exchange of the request by the end of March in the calendar year immediately following the calendar year with the enrollment under §C of this regulation.

Notification to the Exchange under §§E and F of this regulation shall be satisfied if the enrollee provides notice:

(1)

To an Exchange-certified navigator, an Exchange-authorized broker or an Exchange-certified consolidated service center representative; and

(2)

Using any of the methods of communication listed under COMAR 14.35.07.03B.

The effective date of the cancellation under §C of this regulation shall be:

(1)

For a retroactive cancellation under §C(1) or (2) of this regulation:

(a)

The day before the original coverage effective date; or

(b)

A later date, as determined appropriate by the Exchange, based on the circumstances of the cancellation; and

(2)

For a retroactive cancellation under §C(3) of this regulation, the day before the original coverage effective date.

Regulation .09 Reinstatement.Link Copy Citation

An individual’s enrollment shall be reinstated:

(1)

If applicable, under QHP provisions required by COMAR 31.10.25.04;

(2)

If the Exchange determines an error was made by the Exchange that led to an improper termination or cancellation;

(3)

If the carrier determines an error was made by the carrier that led to an improper termination or cancellation; or

(4)

If the Exchange is ordered to reinstate the enrollee by the Maryland Insurance Administration, Office of Administrative Hearings, or a State or federal court.

If the carrier erroneously terminates or cancels an enrollee’s coverage, including if the coverage was terminated or canceled for non-payment of premiums, a carrier shall process a reinstatement transaction from the Exchange.

Regulation .10 Sanctions.Link Copy Citation

A carrier that fails to follow the requirements of this chapter may:

Be denied certification as an authorized carrier;

Be denied certification for a QHP offered for sale by the carrier on the Individual Exchange;

Have the carrier’s certification suspended or revoked;

Have the certification for a QHP offered for sale by the carrier on the Exchange suspended or revoked; or

Be subject to other penalties under Insurance Article, §31-115(k), Annotated Code of Maryland, and COMAR 14.35.16.11.

Chapter 15. Carrier Certification Standards

Regulation .01 Scope.Link Copy Citation

This chapter describes the standards a carrier shall meet to be certified as a carrier authorized to participate on the Maryland Health Benefit Exchange under Insurance Article, §31-115(b)(5), Annotated Code of Maryland, in the Individual and SHOP Exchanges. This chapter does not apply to certification of Individual or SHOP Exchange qualified plans.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

“Active carrier business agreement” means the most recent version of the carrier business agreement provided by the Exchange, signed by the Exchange and the carrier, and on file with the Exchange.

(2)

“Active non-exchange entity agreement” means the most recent version of the non-exchange entity agreement provided by the Exchange, signed by the Exchange and the carrier, and on file with the Exchange.

(3)

“Authorized carrier” means a carrier that holds a current certification of authorization issued by the Exchange as set forth in Regulation .03 of this chapter.

(4)

“Carrier business agreement” means the agreement between the Exchange and the carrier that contains terms and conditions governing compliance with the Annotated Code of Maryland, Exchange policies, and State and federal regulations.

(5)

“Carrier reference manual” means the document developed by the Exchange that provides business rules and operational instructions to authorized carriers participating on the Exchange.

(6)

“Health maintenance organization (HMO)” has the meaning stated in Health-General Article, §19-701(g), Annotated Code of Maryland.

(7)

“Member” means a qualified individual or qualified employee enrolled in a QHP with a particular authorized carrier through the Exchange.

(8)

Member Level Report.

(a)

“Member level report” means a report of the carrier's QHP member enrollment files with the Exchange at a specified time.

(b)

“Member level report” includes:

(i)

Information demonstrating the member enrolled through the Exchange;

(ii)

The coverage effective date;

(iii)

The coverage termination date, if applicable;

(iv)

The termination reason, if applicable;

(v)

The premium amount; and

(vi)

The amount of advanced premium tax credits, if applicable.

(9)

“Metal level” means a QHP at the bronze, silver, gold, or platinum coverage level.

(10)

“Non-exchange entity agreement” means the agreement between the Exchange and the carrier that contains privacy and security provisions.

(11)

“SERFF binder” means the portfolio of information that State laws and regulations require carriers to submit to the Exchange through SERFF.

(12)

“System companion guide” means the document developed by the Exchange that provides instructions to authorized carriers to process enrollment information through electronic data transactions between the Exchange and the carrier.

(13)

“System for Electronic Rate and Form Filing (SERFF)” means the online system the Exchange and the Administration use to accept, review, and approve carrier product and rate filings.

Regulation .03 Carrier Conditions for Participation and Certification — Generally.Link Copy Citation

In order to participate in the Exchanges, carriers must hold a current certificate of authorization issued by the Exchange.

To receive a certificate of authorization from the Exchange, carriers shall:

(1)

Possess a certificate of authority to:

(a)

Act as an insurer and engage in the business of health insurance under Insurance Article, Title 4, Subtitle 1, Annotated Code of Maryland;

(b)

Operate a health maintenance organization under Health-General Article, §19-707, Annotated Code of Maryland;

(c)

Operate as a dental plan organization under Insurance Article, Title 14, Subtitle 4, Annotated Code of Maryland; or

(d)

Operate as a nonprofit health service plan under Insurance Article, §14-108, Annotated Code of Maryland;

(2)

If offering health plans, demonstrate evidence that the carrier:

(a)

Is accredited by the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC); and

(b)

Meets data sharing requirements with the Exchange under the federal accreditation standard at 45 CFR §156.275(c)(5);

(3)

Have a current active carrier business agreement in place, in the form designated by the Exchange;

(4)

Have a current active non-Exchange entity agreement in place, in the form designated by the Exchange; and

(5)

By submitting its application, agree that it will:

(a)

Retain records related to participation in the Exchange for a period of 10 years after participation in the Exchange has ceased; and

(b)

Allow reasonable inspection by the Exchange and, to the extent required by law, other governmental entities including HHS.

The carrier shall remain an authorized carrier until:

(1)

The certificate of authorization expires;

(2)

The Exchange suspends or revokes the authorized carrier’s certification;

(3)

The authorized carrier discontinues offering health benefit plans in the Exchange under Insurance Article, §§15-1212 and 15-1308, Annotated Code of Maryland; or

(4)

The authorized carrier loses its certificate of authority to act as a carrier in the State of Maryland.

When an authorized carrier that offers one or more qualified plans in the Exchange merges into or is acquired by another entity and the merger or acquisition is approved by the Commissioner, the authorized carrier shall:

(1)

Notify the Exchange of the change in a manner to be specified by the Exchange;

(2)

Provide the legal name and Taxpayer Identification Number of the new entity and the effective date of the change at least 30 days prior to the effective date of the merger or acquisition;

(3)

Be deemed to adhere to the requirements of this chapter for the remainder of the affected benefit year; and

(4)

Complete any required modifications to interfaces with the Exchange without undue delay such that operations with the Exchange are not affected or interrupted.

Regulation .04 Application for Authorization.Link Copy Citation

Carriers shall submit an application to the Exchange each year, in the form specified by the Exchange, no later than the first business day of July of the year before the certification is effective.

An application will not be deemed complete until a carrier submits all of the required application elements under §A of this regulation.

The Exchange, within 45 days of receipt of a completed application, shall notify a carrier of the decision to approve or deny the application.

If the Exchange does not provide a carrier notice of a decision to approve or deny a carrier’s application within 45 days of application submission, then the carrier may appeal to MHBE Board of Trustees through a written letter to request an expedited decision within 14 days of the appeal.

An application subject to an expedited decision under §D of this regulation shall be deemed denied by the Exchange if the appeal is not ruled upon by the Board within 14 days.

Regulation .05 Conditions for Participation—Authorized Carrier Conduct.Link Copy Citation

An authorized carrier may not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, or sexual orientation in the administration of a qualified plan.

An authorized carrier shall offer insurance producer compensation for qualified plans offered through the Exchange equal to insurance producer compensation for qualified plans offered outside of the Exchange.

An authorized carrier shall comply with any applicable State laws and regulations regarding marketing by carriers, including:

(1)

Any fair marketing standards developed jointly by the Exchange and the Commissioner under Insurance Article, §31-115(k)(2)(x), Annotated Code of Maryland;

(2)

Insurance Article, §§27-202—27-205, Annotated Code of Maryland, for insurers, nonprofit health service plans, and dental plan organizations; and

(3)

Health-General Article, §19-729, Annotated Code of Maryland, for health maintenance organizations.

An authorized carrier and its officials, employees, agents, and representatives:

(1)

Shall comply with any applicable State laws and regulations regarding marketing by carriers;

(2)

Shall offer plans and plan variations with marketing names that include correct information, without omission of material fact, and do not include content that is misleading; and

(3)

May not employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs in qualified plans.

An authorized carrier shall allow all qualified individuals and qualified employees to enroll in qualified health plans during open enrollment periods designated by the Exchange for the Individual Exchange or the employer for the SHOP Exchange.

An authorized carrier shall allow qualified individuals and qualified employees determined eligible for special enrollment periods by the Exchange to enroll in qualified health plans outside the open enrollment periods.

An authorized carrier shall implement the effective dates of coverage for the Individual Exchange established by the Exchange in accordance with COMAR 14.35.07 and COMAR 14.35.14.14 as specified in enrollment information received from the Exchange.

An authorized carrier shall terminate an enrollee’s coverage in the Individual Exchange only in those circumstances permitted by COMAR 14.35.14.

An authorized carrier shall process and acknowledge enrollment and eligibility information transmitted from the Exchange in accordance with Exchange standards detailed in the System Companion Guide.

An authorized carrier shall reconcile enrollment and eligibility information with the Exchange no less than once a month and upon request of the Exchange in a form and manner designated by the Exchange and detailed in the system companion guide.

An authorized carrier shall provide a member level report to the Exchange no less than once per month, upon request of the Exchange, and in a form and manner designated by the Exchange and detailed in the system companion guide.

An authorized carrier shall notify the Exchange 60 days in advance of a carrier system or data change that may affect the transmission or receipt of data from the Exchange to the carrier.

If an applicant initiates enrollment directly with the authorized carrier for enrollment through the Individual Exchange, the authorized carrier shall direct the individual to file an application through the Individual Exchange.

An authorized carrier shall accept and process an enrollment for a qualified individual or qualified employee that does not include a Social Security number.

Designation of Plans for Re-Enrollment.

(1)

If a carrier terminates a plan in accordance with 45 CFR 147.106(c), the carrier shall submit to the Exchange a template that designates a plan that is an appropriate substitute for the plan that will no longer be available in the next plan year.

(2)

The substitute plan designated by the carrier shall be determined in accordance with COMAR 14.35.07.23C.

Regulation .06 Conditions for Participation — Individual Exchange Premium Payment.Link Copy Citation

An authorized carrier shall follow the premium payment procedures and deadlines under COMAR 14.35.07.11F.

An authorized carrier may establish a premium payment threshold policy under COMAR 14.35.07.11G.

An authorized carrier may not use a payment made to effectuate coverage under COMAR 14.35.07.11F(1) to pay outstanding balances attributed to previously terminated coverage of the qualified individual.

An authorized carrier in the Individual Exchange shall calculate that the premium for coverage lasting less than 1 month equals the product of:

(1)

The premium for 1 month of coverage divided by the number of days in the month; and

(2)

The number of days for which coverage is being provided in the month.

An authorized carrier shall accept premium and cost-sharing payments from the following third-party entities:

(1)

Ryan White HIV/AIDS Program under Title XXVI of the Public Health Service Act;

(2)

Indian tribes, tribal organizations, or urban Indian organizations; and

(3)

State and federal government programs.

Establishment of Standard Policies for Termination of QHPs Due to Non-payment of Premiums.

(1)

An authorized carrier shall establish a standard policy for termination of enrollment of enrollees through the Exchange due to non-payment of premiums under COMAR 14.35.14.06B.

(2)

The authorized carrier’s standard policy shall:

(a)

Include the grace period for enrollees receiving Advanced Premium Tax Credits set forth in Insurance Article, §15-1315(c)—(e), Annotated Code of Maryland;

(b)

Include the grace period for enrollees not receiving an Advanced Premium Tax Credit set forth in Insurance Article, §15-209, Annotated Code of Maryland, COMAR 31.10.25.04C, and COMAR 31.12.07.05D;

(c)

Be applied uniformly to enrollees in similar circumstances;

(d)

Specify whether the authorized carrier has a premium payment threshold policy under COMAR 14.35.07.11G; and

(e)

If the carrier has a premium payment threshold policy, specify the authorized carrier’s premium payment threshold policy.

Location of Premium Payment Information.

(1)

An authorized carrier shall make information available to enrollees through an Internet link that is displayed prominently in the enrollee’s authorized carrier’s monthly premium payment billing notice.

(2)

This information shall be available on:

(a)

The authorized carrier’s enrollee website;

(b)

The authorized carrier’s enrollee Internet portal; and

(c)

Upon request by an enrollee.

Regulation .07 Conditions for Participation — Individual Exchange Carrier Notice Requirements.Link Copy Citation

An authorized carrier shall provide enrollees newly effectuating coverage an enrollment information package that is written in plain language and in a manner that is accessible to individuals living with disabilities and individuals who have limited English proficiency.

If an enrollee is delinquent on premium payment, the carrier shall provide the enrollee with notice of such payment delinquency.

If an authorized carrier terminates an enrollee's coverage or enrollment in a qualified plan through the Exchange in accordance with COMAR 14.35.14 and 45 CFR §155.430(b)(2)(i), (ii), or (iii), the authorized carrier shall, promptly and without undue delay provide the enrollee with a notice of termination that includes:

(1)

The termination effective date; and

(2)

The reason for termination.

An authorized carrier shall follow all other carrier notice requirements under Insurance Article, Titles 15 and 31, Annotated Code of Maryland, pertaining to the individual and small group Exchanges, and 45 CFR Parts 147, 154, 155, and 156.

Regulation .08 Requirements for Qualified Plans.Link Copy Citation

The authorized carrier shall offer in the Exchange only plans that the Exchange certifies as qualified plans under COMAR 14.35.16.

The authorized carrier shall ensure that each of its plans comply with the plan certification requirements in COMAR 14.35.16 on an ongoing basis.

An authorized carrier shall offer no more than:

(1)

Four benefit designs per metal level in the Individual Exchange and four benefit designs per metal level in the SHOP Exchange in plan year 2024 and prior plan years; and

(2)

Three benefit designs per metal level in the Individual Exchange and four benefit designs per metal level in the SHOP Exchange beginning in plan year 2025.

An authorized carrier offering stand-alone dental plans shall offer no more than one benefit design at the same actuarial value per network type.

As set forth in Insurance Article, §31-115(b)(5), Annotated Code of Maryland, the authorized carrier:

(1)

Shall offer in each Exchange, the Individual and the SHOP, in which the authorized carrier participates, at least one qualified health plan:

(a)

At a bronze coverage level;

(b)

At a silver coverage level; and

(c)

At a gold coverage level;

(2)

If the authorized carrier participates in the Individual Exchange and offers any health benefit plan in the individual market outside the Exchange, shall offer at least one qualified health plan at the silver level and one at the gold level in the individual market outside the Exchange;

(3)

Shall charge the same premium rate for the same qualified health plan regardless of whether the qualified health plan is offered through the Exchange, through an insurance producer outside the Exchange, or directly from a carrier;

(4)

May not vary rates for a SHOP qualified employer during the employer's plan year; and

(5)

Shall comply with the prohibition on cancellation fees and penalties for termination of coverage, as set forth in the Insurance Article, §31-108(d), Annotated Code of Maryland.

Regulation .09 Network Adequacy.Link Copy Citation

For each qualified plan that the authorized carrier seeks to offer for sale through the Individual Exchange or the SHOP Exchange, the authorized carrier shall:

Follow the Maryland Insurance Administration network adequacy and network reporting regulations set forth under COMAR 31.10.44 or COMAR 31.10.45;

Complete an attestation in the carrier application under Regulation .04 of this chapter indicating carrier compliance with COMAR 31.10.44 or COMAR 31.10.45; and

Submit a document providing consumers with information on the carrier’s network that is suitable for publishing in qualified plan shopping in the Individual Exchange in a form and manner detailed by the Individual Exchange.

Regulation .10 Waiver Authority.Link Copy Citation

The Exchange, with the approval of the Exchange Board of Trustees, and for reasons solely within the discretion of the Exchange, may grant a waiver to a specific provision of the application for certification, with or without conditions.

A waiver may only be granted to the extent it does not conflict with the provisions of Insurance Article, Annotated Code of Maryland, or applicable federal and State law.

A carrier may submit a request for a waiver on a form developed by the Exchange.

Carriers who are newly seeking accreditation from outside entities and have not yet received such accreditation by the Exchange’s application deadline should use the waiver process to seek waiver or modification of this condition.

The request shall state:

(1)

The provision from which a waiver is sought;

(2)

The reason the carrier is unable to comply with the provision; and

(3)

The reason that compliance with the provision will impose a substantial hardship.

The Exchange may grant a waiver if:

(1)

The Exchange determines that compliance with the provision from which the waiver is sought cannot be accomplished without substantial hardship;

(2)

The waiver will not conflict with applicable State and federal law; and

(3)

The waiver is in the best interests of the State.

Final Written Decisions on Requests for Waivers.

(1)

The Exchange shall issue a final written decision on a request for a waiver that is submitted under §A of this regulation within 45 days from receipt of the request and all supporting information for the waiver by the Exchange.

(2)

If the Exchange grants a waiver, the decision shall include:

(a)

The duration of the waiver; and

(b)

Any conditions imposed by the Exchange.

(3)

A request for a waiver may be denied if:

(a)

The Exchange determines that the conditions of §D of this regulation are not satisfied;

(b)

A waiver is not in the best interests of the State; or

(c)

The waiver will conflict with applicable State or federal laws.

(4)

A denial may not be appealed.

(5)

The Exchange shall notify the carrier of the decision by mail or electronically.

The Exchange may revoke a waiver if it appears that the reasons for granting the waiver have ceased to exist.

The Exchange’s decision and the request for waiver shall be subject to public disclosure.

Regulation .11 Authorization Renewals.Link Copy Citation

The Exchange shall review the performance of authorized carriers on an annual basis.

Authorized carriers shall submit information in a form and manner required by the Exchange about Exchange-specific complaints and grievances, upon request.

Chapter 16. Plan Certification Standards

Regulation .01 Scope.Link Copy Citation

This chapter describes the standards a qualified health plan shall meet in order to be certified as a QHP by the Maryland Health Benefit Exchange under Insurance Article, §31-115, Annotated Code of Maryland. This chapter addresses standards for QHP certification for both the Individual and SHOP Exchanges, unless otherwise noted. Standards for carrier certification for the Exchange are addressed in COMAR 14.35.15. This chapter does not address plan certification standards for QDPs or QVPs.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

Annual Letter to Issuers.

(a)

“Annual Letter to Issuers” means a written communication, issued by the Exchange, which should be interpreted in the same manner as the Annual Letter to Issuers that is distributed by the federally facilitated Exchange.

(b)

“Annual Letter to Issuers” includes instruction on how issuers shall meet compliance with QHP certification standards, establishes timelines on implementation, details Exchange expectations of issuer compliance with such certification standards, and alerts issuers of policy developments.

(2)

“Essential community provider” means:

(a)

An essential community provider as defined in 45 CFR §156.235(c);

(b)

A local health department;

(c)

An outpatient mental health center, as described in COMAR 10.21.20, or a substance use disorder treatment provider, as described in COMAR 10.09.80.03B(1) and (3), that is licensed or approved by the State Department of Health and Mental Hygiene as a program or facility; or

(d)

A school-based health center.

(3)

“Similarly situated” means alike in all relevant ways.

Regulation .03 Qualified Health Plan Certification — In General.Link Copy Citation

An authorized carrier shall apply for a certificate of authorization for each health benefit plan the carrier intends to offer on the Exchange.

The authorized carrier shall no longer offer a QHP on the Exchange, if:

(1)

The plan’s certification of authorization expires;

(2)

The plan is decertified by the Exchange;

(3)

The carrier elects to withdraw from the market with the Exchange, under 45 CFR §156.290; or

(4)

The carrier elects not to offer or renew the QHP on the Exchange in accordance with Insurance Article, Annotated Code of Maryland.

With respect to per-member premium rating for family coverage offered through a QHP on the Exchange, a carrier shall cap the premium rating for non-spousal dependents at three non-spousal dependents under the age of 21 for all plans authorized for sale under this chapter.

Regulation .04 Qualified Health Plan Certification — Application.Link Copy Citation

Each authorized carrier shall annually submit an application, in a form specified by the Annual Letter to Issuers, for each health benefit plan intended to be certified as a QHP to be offered on the Exchange.

A carrier shall submit a completed application, including all required information and submissions under this regulation, to the Exchange.

The Exchange shall notify a carrier of the application status within 45 days of receipt of a completed application.

If an application is determined incomplete, the Exchange shall notify a carrier of the application status within 45 days of the initial submission.

Information Submission.

(1)

An authorized carrier shall submit an initial submission containing the information required under §§E and F of this regulation and Regulations .04—.10 of this chapter as part of the application under §B of this regulation and detailed through the Annual Letter to Issuers.

(2)

If requested by the Exchange, an authorized carrier shall submit a supplement to its initial submission under §E(1) of this regulation.

In accordance with Insurance Article, §31-115(g)(2), Annotated Code of Maryland, upon request, an authorized carrier shall provide in its application a description of the health benefit plan, in plain language and in a form specified by the Annual Letter to Issuer, that includes:

(1)

Claims payment policies and practices;

(2)

Data on enrollment, disenrollment, number of claims denied (including in whole and in part), and rating practices, if applicable;

(3)

Information on cost sharing and payments with respect to any out-of-network coverage; and

(4)

Any other information as determined appropriate by the Exchange.

An authorized carrier shall provide in its application, in a form specified in the Annual Letter to Issuers, the following information about the health benefit plan:

(1)

Plan, benefit, and cost sharing;

(2)

Plan information for the renewal of QHP enrollment;

(3)

Unified rate review template;

(4)

Prescription drug cost sharing and formulary;

(5)

Provider network;

(6)

Service area, including justifications for partial county service areas;

(7)

Rate and premiums;

(8)

Actuarial information required to be submitted to the Exchange under 45 CFR §155.1030(b);

(9)

Provider directory data as specified in Regulation .07 of this chapter;

(10)

Summaries of benefits and coverage, under 45 CFR §147.200, for each cost-sharing reduction variation;

(11)

Essential community providers contracted to participate within the health benefit plan’s provider network; and

(12)

Any other information the carrier would like to provide to the Exchange to supplement the application.

An authorized carrier shall comply with the rate and form review procedures, including review of compliance with essential health benefits requirements, established by the Commissioner.

Data and information submitted to the Exchange may be provided to the Commissioner, if requested, for consideration in the Commissioner’s annual QHP rate and form review process.

The authorized carrier shall provide to the Exchange the rate justification forms filed with the Commissioner for each QHP certification application the authorized carrier submits to the Exchange.

Regulation .05 Qualified Health Plan Certification — Plan Service Areas.Link Copy Citation

As part of a QHP certification application, an authorized carrier shall submit:

(1)

A description of the boundaries of the service area of any health benefit plan that is smaller than the State of Maryland; and

(2)

For any service area smaller than the State of Maryland, an explanation of the reason for the smaller service area, including a justification that the boundaries are not designed to discriminate against individuals excluded from the health benefit plan’s service area.

Carriers submitting a justification under §A(2) of this regulation are not required to submit a justification in subsequent years, after the initial justification submission, if there has been no change in the carrier’s health benefit plan service areas.

After the initial data submission under Regulation .04E of this chapter, a change to a health benefit plan’s service area shall be made only by petition to the Exchange and:

(1)

Because the carrier cannot secure enough providers; or

(2)

Because of an Exchange request to serve an unmet need.

After the final data submission under Regulation .04E of this chapter, a change to the health benefit plan’s service area shall be permitted only if the change is an expansion of the health benefit plan’s service area.

Regulation .06 Qualified Health Plan Certification — Provider Directories Specific to Individual Exchange.Link Copy Citation

An authorized carrier shall submit to the Individual Exchange the health benefit plan’s provider directory information for each QHP’s network.

Provider directory data shall include the requirements specified in Insurance Article, §15-112(n)(3), Annotated Code of Maryland, as well as be current, accurate, and complete.

Provider directory data may include:

(1)

Program and community health center names;

(2)

Providers’ affiliations with certain facilities, programs, and centers; and

(3)

Any other information that may assist consumers in searching for specific programs or centers by name.

Updated provider directory data requested in §B of this regulation shall be submitted in the format required by the Individual Exchange at least once every 15 calendar days.

Regulation .07 Qualified Health Plan Certification — Essential Community Providers.Link Copy Citation

For each health benefit plan that a carrier seeks to offer through the Exchange, the carrier shall make all good faith efforts to contract with at least 35 percent of available essential community providers in the plan’s service area as part of each plan’s provider network, except as specified in §C of this regulation.

Additional Essential Community Providers.

(1)

Included with its application for certification and in the form provided by the Exchange, the carrier may write in additional essential community providers that are not included in the definition for essential community provider under Regulation .02B of this chapter.

(2)

If available, the carrier shall include the following information when writing in additional essential community health providers:

(a)

The provider’s zip code reflecting a provider location within a low-income zip code or Health Professional Shortage Areas included on the “Low-Income and Health Professional Shortage Area Zip Code Listing” from CMS;

(b)

The provider’s service street address, which may not be a Post Office Box number; and

(c)

The National Provider Identifier (NPI) number, if the provider has such a number, or an alternate identification, such as a Tax Identification Number, if the provider does not have such a number.

(3)

The authorized carrier shall provide information under this section as part of the application submitted under Regulation .04 of this chapter.

Carriers Who Are Unable to Meet Contracting Requirements.

(1)

If the authorized carrier cannot meet the standard under this section, the authorized carrier may satisfy this requirement under the alternative standard.

(2)

To meet the alternative standard, the authorized carrier shall provide a narrative explanation of the authorized carrier’s justification that the carrier includes access to sufficient essential community providers within the health benefit plan’s network.

(3)

The narrative explanation shall describe the extent to which the authorized carrier’s provider sites are accessible to, and have services that meet the needs of, specific underserved populations, including:

(a)

Individuals with HIV/AIDS, including those with co-morbid behavioral health conditions;

(b)

American Indians and Alaska Natives;

(c)

Low-income and underserved individuals seeking women’s health and reproductive health services; and

(d)

Other specific populations served by essential community providers in the plan’s service area.

(4)

The narrative explanation shall demonstrate that low-income members receive appropriate access to care and satisfactory service, including performance on provider quality and patient satisfaction metrics, as specified in the Annual Letter to Issuers.

For each health benefit plan that a carrier seeks to offer through the Exchange, the carrier shall make all good faith efforts to contract with at least one available essential community provider of each essential community provider type, under §E of this regulation, in each county, or partial county, of the plan’s service area as part of each plan’s provider network.

Authorized carriers shall offer the same provider contract terms in good faith to the following essential community providers that a willing, similarly situated, non-essential community provider would accept or has accepted from the authorized carrier to the following provider types:

(1)

All available Indian Health Care Providers in the plan’s service area;

(2)

Willing local health departments under Insurance Article, §15-112(b)(3)(iii), Annotated Code of Maryland, in the plan’s service area; and

(3)

For each county in the plan’s service area, at least one provider from the following provider types, if such a provider is available and provides the medical or dental services, as applicable to plan type:

(a)

A health care provider defined in §340B(a)(4) of the Public Health Services Act;

(b)

An outpatient mental health center as described in COMAR 10.21.20;

(c)

A substance use disorder treatment provider as described at COMAR 10.09.80.03B(1) and (3);

(d)

A school based-health center;

(e)

A health care provider described in §1927(c)(1)(D)(i)(IV) of the Social Security Act; and

(f)

A State-owned, government-owned, or not-for-profit family planning services site that does not receive federal funding.

An authorized carrier shall submit verification of essential community provider contract offers to the Exchange upon request.

Regulation .08 Qualified Health Plan Certification — Network Adequacy.Link Copy Citation

Each health benefit plan shall meet the network adequacy standards stated in 45 CFR §156.230, Insurance Article, §15-112, Annotated Code of Maryland, and COMAR 31.10.44.

Each health benefit plan shall meet the provider panel sufficiency requirements under COMAR 31.10.34.04A.

Regulation .09 Qualified Health Plan Certification — Covered Prescription Drugs and Formularies.Link Copy Citation

An authorized carrier’s application under Regulation .04A of this chapter shall identify drugs covered under the health benefit plan’s medical benefit.

Drug Formulary List Location.

(1)

An authorized carrier shall provide the Internet address for the drug formulary for each health plan with the application submitted for the health benefit plan to the Exchange under Regulation .04A of this chapter.

(2)

The Internet address required under §B(1) of this regulation shall link directly to the health benefit plan’s list of covered drugs without further navigation.

(3)

The health benefit plan’s list of covered drugs shall:

(a)

Include plain language drug category information for each drug category;

(b)

Include information on utilization management tools such as prior authorization, step therapy, quantity limitations, and generic substitutions; and

(c)

Be up to date, accurate, and complete.

An authorized carrier may classify a covered drug as a preventative drug covered at zero cost and shall identify any drugs so covered in its formulary.

Drug Exception Process.

(1)

An authorized carrier shall establish a drug exception process by which an enrollee can request access to a drug not on the plan’s formulary list in standard situations, as required by Insurance Article, §15-831(c), Annotated Code of Maryland, and 45 CFR §156.122(c).

(2)

A carrier shall notify the enrollee of its coverage decision no later than 72 hours after receipt of the request for exception.

A carrier shall follow the external review process established by the Administration for advice from an independent review organization for denied requests as described in COMAR 31.10.19.

A carrier shall establish a process for the emergency review of denials that is compliant with State and federal statute and regulation.

Regulation .10 Qualified Health Plan Certification — Waiver Authority.Link Copy Citation

The Exchange, with the approval of the Board, may grant a waiver to a specific provision of this chapter, with or without conditions, under the procedure in COMAR 14.35.15.10.

Regulation .11 Qualified Health Plan Denial, Suspension, and Revocation of Certification and Other Remedies.Link Copy Citation

If the Exchange determines that a carrier has failed to comply with this chapter, Insurance Article, Title 31, Annotated Code of Maryland, or any other federal or State laws or regulations applicable to carrier offerings in the Exchange that are not otherwise specified in Insurance Article, §31-115(k), Annotated Code of Maryland, the Exchange may initiate one or more of the following actions against the carrier:

(1)

Deny certification for participation in the Exchange;

(2)

Suspend the carrier’s certification for participation in the Exchange;

(3)

Revoke the carrier’s certification for participation in the Exchange; or

(4)

Another remedy defined under §D of this regulation.

Subject to the contested case hearing provisions of State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland, and the limitations stated in Insurance Article, §31-115(k), Annotated Code of Maryland, the Exchange may deny certification to a health benefit plan, or suspend or revoke the certification of a qualified health plan, based on a finding that the health benefit plan or qualified health plan does not satisfy requirements or has otherwise violated standards for certification that are established under this regulation and interim policies adopted by the Exchange, and not otherwise under the regulatory and enforcement authority of the Commissioner, including requirements and standards related, but not limited, to:

(1)

Enrollment;

(2)

Essential community providers;

(3)

Complaints and grievances involving the Individual Exchange;

(4)

Network adequacy;

(5)

Quality;

(6)

Transparency;

(7)

Race, ethnicity, language, interpreter need, and cultural competency (RELICC);

(8)

Plan service area, including demographics;

(9)

Accreditation;

(10)

Authorization of the plan’s sponsoring carrier; and

(11)

Fair marketing standards developed jointly by the Individual Exchange and the Commissioner.

Instead of or in addition to denying, suspending, or revoking plan certification, the Exchange may impose other remedies or take other actions, and to the extent not otherwise under the regulatory and enforcement authority of the Commissioner, including:

(1)

Requiring a corrective action to remedy a violation of or failure to comply with standards for certification; and

(2)

Imposing a penalty not exceeding $5,000 for each violation of or failure to comply with standards for certification.

In determining the amount of a penalty under §C of this regulation, the Exchange shall consider:

(1)

The type, severity, and duration of the violation;

(2)

Whether the plan or carrier knew or should have known of the violation;

(3)

The extent to which the plan or carrier has a history of violations; and

(4)

Whether the plan or carrier corrected the violation as soon as they knew or should have known of the violation.

The penalties available to the Exchange under this regulation shall be in addition to any criminal or civil penalties imposed for fraud or other violation under any other State or federal law.

Regulation .12 Qualified Health Plan Certification — On-going Compliance with Qualified Health Plan Certification Standards.Link Copy Citation

The Exchange may conduct compliance reviews of a QHP during the plan benefit year.

The Exchange may require an authorized carrier to develop, submit for approval, and follow, as amended by the Exchange, a corrective action plan for compliance issues noted by the Exchange during its compliance review of a QHP.

Chapter 17. State Reinsurance Program

Regulation .01 Scope.Link Copy Citation

This chapter sets forth the structure, implementation, and eligibility standards for the State Reinsurance Program, as required under Insurance Article, §31-117, Annotated Code of Maryland.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

(2)

“Annual Letter to Issuers” means a written communication, issued by the Individual and SHOP Exchange, that:

(a)

Provides guidance on how the Exchange will interpret laws and regulations, issues reminders regarding requirements of and compliance with relevant laws and regulations, and provides notification of policy developments; and

(b)

Instructs issuers on how to meet compliance with QHP certification standards, establishes timelines on implementation, and details Exchange expectations of issuer compliance with such certification standards.

(3)

“Attachment point” means the threshold dollar amount for claims costs incurred by a health insurance carrier for an enrolled individual’s covered benefits in a benefit year, after which threshold the claims costs for such benefits are eligible for reinsurance payments.

(4)

“Benefit year” means a calendar year for which a health plan provides coverage for health benefits.

(5)

“Board” has the meaning stated in Insurance Article, §31-101, Annotated Code of Maryland.

(6)

“Carrier business agreement” means the annual agreement between the Exchange and the carrier that contains terms and conditions governing compliance with the Annotated Code of Maryland, and State and federal regulations.

(7)

“Carrier Reference Manual” means the document developed by the Exchange that provides business rules and operational instructions to authorized carriers participating on the Individual and SHOP Exchange.

(8)

“Carrier-specific adjustment factors” means a set of coefficients that modify payments under the State Reinsurance Program and that replicate the modified payments that would occur by applying the Dampening Factor to the Federal Risk Adjustment Program.

(9)

“Claims-to-premium ratio” means the resulting ratio produced by dividing total claims incurred (less State Reinsurance Program payments, federal risk adjustment payments, and federal high risk pool reinsurance payments) by the premium amount collected for a reinsurance-eligible plan.

(10)

“Coinsurance rate” means the rate at which the applicable reinsurance entity will reimburse the health insurance issuer for claims costs incurred for an enrolled individual’s covered benefits in a benefit year after the attachment point and before the reinsurance cap.

(11)

“Dampening factor” means a coefficient that modifies payments under the State Reinsurance Program to account for RA/RI program interaction to the extent that the claims-to-premium ratio between payers and receivers under the risk adjustment is normalized.

(12)

“Individual Exchange” has the meaning stated in Insurance Article, §31-101(h), Annotated Code of Maryland.

(13)

Payment Parameters.

(a)

“Payment parameters” means the attachment point, coinsurance rate, and reinsurance cap for reinsurance payments.

(b)

“Payment parameters” includes a dampening factor, if determined appropriate by the Board.

(14)

“Qualified health plan (QHP)" has the meaning stated in Insurance Article, §31-101, Annotated Code of Maryland.

(15)

“RA/RI program interaction” refers to payments received by a carrier for the enrolled population whose risk and claims experience would be eligible for payments under both the Federal Risk Adjustment Program and the State Reinsurance Program, such that the resulting full payment would result in a normalized claims-to-premium ratio, for the enrolled population identified in this definition, that is less than one.

(16)

“Reinsurance cap” means the threshold dollar amount for total claims costs paid by a health insurance issuer for an enrolled individual’s covered benefits, after which, the claims costs for such benefits are no longer eligible for reinsurance payments.

(17)

“Reinsurance-eligible plan” means any health benefit plan offered in the individual market, except for the limitations and exceptions provided in Regulation .03 of this chapter.

(18)

“Risk adjustment covered plan” means, for the purpose of the risk adjustment program, any health insurance coverage offered in the individual or small group market with the exception of grandfathered health plans, group health insurance coverage described in 45 CFR §146.145(c), individual health insurance coverage described in 45 CFR §148.220, and any plan determined not to be a risk adjustment covered plan in the applicable federally certified risk adjustment methodology.

(19)

“Section 1332 State Innovation Waiver” means the waiver for state innovation filed by the State of Maryland, pursuant to 42 U.S. Code §18052.

(20)

“State Reinsurance Program” means the market stabilization program identified in Insurance Article, §31-117, Annotated Code of Maryland.

Regulation .03 Eligibility for Receipt of Reinsurance Payments.Link Copy Citation

Except as provided in §B of this regulation, a qualified health plan is eligible to receive reinsurance payments from the State Reinsurance Program, provided that the qualified health plan is offered by a carrier that:

(1)

Is authorized to offer individual non-Medigap health benefit plans in Maryland;

(2)

Complies with the assessment under Insurance Article, §6-102.1, Annotated Code of Maryland; and

(3)

Meets all obligations set forth in the Carrier Business Agreement.

The following health benefit plans are not eligible to receive reinsurance payments:

(1)

Grandfathered health benefit plans as defined in §1251 of the Affordable Care Act;

(2)

Health benefit plans that are not required to submit reinsurance contributions under Insurance Article, §6-102.1, Annotated Code of Maryland;

(3)

Group health insurance plans, including but not limited to those identified in Insurance Article, §15-1202, Annotated Code of Maryland;

(4)

Short-term, limited duration insurance plans, including but not limited to those identified in Insurance Article, §15-1301, Annotated Code of Maryland; and

(5)

Association health plans, including but not limited to those offered by associations identified in Insurance Article, §15-1301, Annotated Code of Maryland.

Carrier State Reinsurance Program Accountability Report. For each year a carrier which offers a reinsurance-eligible plan participates in the State Reinsurance Program, the carrier shall submit to the Board a report on a date no later than that provided in the Annual Letter to Issuers, to be made publically available on the Individual Exchange website upon review of the Board, detailing carrier action to manage the costs and utilization of enrollees whose claims are reimbursable under the State Reinsurance Program. At minimum, the report shall include information related to the following:

(1)

The initiatives and programs the carrier administers to manage cost and utilization of enrollees whose claims are reimbursable under the State Reinsurance Program in a narrative summary format;

(2)

The total population of enrollees whose claims are reimbursable under the State Reinsurance Program, the allocation of these enrollees across each of the initiatives and programs identified in §C(1) of this regulation, and the allocation of these enrollees who do not participate in the initiatives and programs identified in §C(1) of this regulation;

(3)

The effectiveness of the initiatives and programs identified in §C(1) of this regulation as measured by the estimated reduction of claims and utilization by the enrollees identified in §C(1) of this regulation;

(4)

The actions the carrier will take to improve on the effectiveness estimates identified in §C(3) of this regulation;

(5)

The estimated savings to the State Reinsurance Program based upon the effectiveness identified in §C(3) of this regulation;

(6)

The estimated rate impact of the initiatives and programs identified in §C(1) of this regulation;

(7)

The methodology utilized to determine which programs to include in §C(1) of this regulation, estimated effectives in §C(3) of this regulation, and estimated savings to the State Reinsurance Program in §C(5) of this regulation; and

(8)

Population health initiatives and outcomes for Individual Exchange enrollment.

Regulation .04 Calculation of Reinsurance Payments Under the State Reinsurance Program.Link Copy Citation

A carrier of a reinsurance-eligible plan, as provided for in Regulation .03 of this chapter, becomes eligible for reinsurance payments from the State Reinsurance Program when its claims costs for individual enrollees’ covered benefits in a benefit year exceed the attachment point established under the process identified in §B of this regulation.

Each year the Board shall set the payment parameters for the State Reinsurance Program by determining the following factors:

(1)

An attachment point;

(2)

A coinsurance rate;

(3)

A reinsurance cap; and

(4)

A market-level dampening factor provided by the Commissioner, if determined necessary by the Board.

For each benefit year after 2019, the Board shall set the estimated payment parameters for the State Reinsurance Program on or before April 1 of the calendar year proceeding the applicable plan year.

For each benefit year after 2019, the Board shall set the final payment parameters for the State Reinsurance Program before December 31 of the calendar year proceeding the applicable plan year.

The Exchange shall calculate each reinsurance payment made from the State Reinsurance Program as the product of the coinsurance rate multiplied by the carrier’s claims costs for an individual enrollee’s covered benefits that the carrier incurs in the applicable benefit year between the attachment point and reinsurance cap. The Exchange shall apply the carrier-specific adjustment factor provided in §B(4) of this regulation to the product calculated above to determine the adjusted reinsurance payment.

If the Individual Exchange determines that all reinsurance payments requested under the State Reinsurance Program by reinsurance-eligible plans in the State for a benefit year will not be equal to the amount of funding allocated to the State Reinsurance Program, the Individual Exchange shall determine a uniform pro rata adjustment to be applied to all such requests for reinsurance payments in the State.

Regulation .05 Data Collection and Maintenance for Reinsurance Payments.Link Copy Citation

The carriers of reinsurance-eligible plans shall submit to the Exchange data required to determine reinsurance payments as described in Regulation .06 of this chapter, or shall provide access to such data, according to the data requirements specified by the Exchange in the Annual Letter to Issuers.

The Individual Exchange shall establish a process through which an issuer of a reinsurance-eligible plan that does not generate individual enrollee claims in the normal course of business may use estimated claims costs to make a request for payment, or to submit data to be considered for reinsurance payments, in accordance with the requirements of Regulation .09 of this chapter. The State shall ensure that such requests for reinsurance payment, or a subset of such requests, are subject to validation.

The Individual Exchange shall maintain documents and records relating to the State Reinsurance Program, whether paper, electronic, or in other media, for each benefit year for at least 10 years. The documents and records shall be sufficient to enable the evaluation of the State Reinsurance Program’s compliance with federal standards.

The Individual Exchange shall ensure that the collection of personally identifiable information is limited to information reasonably necessary for use in the calculation of reinsurance payments. Any use and disclosure of personally identifiable information shall be limited to those purposes for which the personally identifiable information was collected, including for purposes of data validation.

The Individual Exchange shall maintain standards that provide administrative, physical, and technical safeguards for the personally identifiable information consistent with applicable State and federal standards.

Regulation .06 Disbursement of Reinsurance Payments.Link Copy Citation

The Individual Exchange shall make reinsurance payments to the carrier of a reinsurance-eligible plan after it receives a valid claim for payment from that carrier in accordance with the processes established in Regulation .07 of this chapter.

For each applicable benefit year, the Individual Exchange shall:

(1)

Notify carriers annually of reinsurance payments under the State Reinsurance Program payment parameters to be made for the applicable benefit year no later than September 30 of the year following the applicable benefit year; and

(2)

Provide to each issuer of a reinsurance-eligible plan the calculation of total reinsurance payment requests made under the State Reinsurance Program payment parameters.

Regulation .07 Request for Reinsurance Payment.Link Copy Citation

A carrier may make a request for payment when a carrier’s claims costs for an enrollee of a reinsurance-eligible plan has met the criteria for reinsurance payment set forth by the Board for the applicable benefit year.

A carrier of a reinsurance-eligible plan shall make requests for payment in accordance with the requirements of the Annual Letter to Issuers for the applicable benefit year.

Regulation .08 Document Retention and Audits.Link Copy Citation

A carrier of a reinsurance-eligible plan shall maintain documents and records, whether paper, electronic, or in other media, sufficient to substantiate the requests for reinsurance payments made pursuant to Regulation .07 of this chapter for a period of at least 10 years and shall make those documents and records available upon request by the Board or the Individual Exchange or its designee to any such entity for purposes of verification, investigation, audit, or other review of reinsurance payment requests.

The Individual Exchange may audit a carrier of a reinsurance-eligible plan to assess its compliance with the requirements of this chapter. The issuer shall ensure that its relevant contractors, subcontractors, or agents cooperate with any audit under this section. If an audit results in a finding of material weakness or significant deficiency with respect to compliance with any requirement of these regulations, the carrier shall complete all of the following:

(1)

Within 30 calendar days of the issuance of the final audit report, provide a written corrective action plan to the Exchange for approval;

(2)

Implement the corrective action plan; and

(3)

Provide to the Exchange written documentation of the corrective actions once taken.

Regulation .09 State Reinsurance Program Surplus.Link Copy Citation

For the Benefit Year 2019 and after, the Individual Exchange shall reserve any surplus, after all reinsurance payments have been remitted, for claims in future years of the State Reinsurance Program.

Chapter 18. Small Business Health Options Program

Regulation .01 Scope.Link Copy Citation

This chapter sets forth the requirements for the Small Business Health Options Program. This chapter does not address the individual exchange or qualified dental plans or qualified vision plans.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

“Common law employee” has the meaning stated in 20 CFR §404.1007.

(2)

“Date of enrollment’’ means the date of enrollment of an individual covered under a group health plan or, if earlier, the first day of the waiting period for such enrollment.

(3)

“Employer group health insurance coverage” means health coverage offered by an employer to an employee and the employee’s dependents, if eligible, under:

(a)

Government health coverage, such as the Federal Employees Health Benefit program;

(b)

Health coverage offered in the small or large group market by an employer within a state; or

(c)

Grandfathered health coverage offered by an employer in a group market.

(4)

“Full-time employee” means a common law employee working on average, at least 30 hours per week.

(5)

“Independent contractor” means a 1099 employee working 30 or more hours per week.

(6)

“Member” means any person enrolled in a health benefit plan.

(7)

“Part-time employee” means a common law employee working fewer than 30 hours per week, or seasonal worker working more than 120 days per year.

(8)

“Participation rate” means the percentage of eligible employees electing to participate in a health benefit plan out of all eligible employees.

(9)

“Participation requirement” means a policy provision, or a carrier’s underwriting guideline if there is no such provision, which requires that a group attain a certain participation rate in order for a carrier to accept the group for enrollment in the plan.

(10)

“Qualified employee’’ means an employee who:

(a)

Works on a full-time basis with a normal work week of thirty or more hours, but does not include an employee who works on a temporary or substitute basis; and

(b)

Is hired to work for a period of not less than 5 months.

(11)

“Qualified employer” means a small employer that elects to make its full-time employees and, at the option of the employer, some or all of its part-time employees eligible for one or more qualified health plans offered through the SHOP Exchange, provided that the employer:

(a)

Has its principal place of business in the State and elects to provide coverage through the SHOP Exchange to all of its eligible employees, wherever employed; or

(b)

Elects to provide coverage through the SHOP Exchange to all of its eligible employees who are principally employed in the State.

(12)

“Rescission” means a cancellation or discontinuance of coverage that has retroactive effect.

(13)

“Waiting period” means the period of time that must pass before coverage for a qualified employee who is otherwise eligible to enroll under the terms of a small group health plan can become effective.

Regulation .03 Eligibility for SHOP Exchange.Link Copy Citation

Nondiscrimination. No policy shall exclude a qualified employee or dependent on the basis of age, sex, sexual orientation, gender identity, occupation, actual or expected health condition, claims experience, duration of coverage, or medical condition.

SHOP Exchange Employer Eligibility.

(1)

An employer is eligible to purchase insurance on the SHOP Exchange if it meets the following requirements as established by Insurance Article, §31-101(aa), Annotated Code of Maryland:

(a)

Has, on average, 50 or fewer employees during the preceding calendar year;

(b)

Has at least one full-time employee who is not the spouse or other dependent of the owner;

(c)

Has its principal place of business in Maryland;

(d)

Elects to offer, at a minimum, all full-time employees coverage in a qualified health plan through the SHOP Exchange; and

(e)

Either:

(i)

Elects to provide coverage through the SHOP to all eligible employees, wherever employed; or

(ii)

Elects to provide coverage through the SHOP to all of its eligible employees who are principally employed in Maryland.

(2)

For the purpose of determining the number of qualified employees, a business shall be considered to be one qualified small business or group if:

(a)

It is eligible to file a combined tax return for purpose of State taxation; or

(b)

It comprises two or more companies that are part of the same parent-subsidiary controlled group, as defined by 26 CFR §1.1563-1(a)(2).

New Employers. An employer that was not in existence for the entirety of the preceding calendar year shall have eligibility determined as established by Insurance Article, §31-101, Annotated Code of Maryland.

Eligibility Application. All qualified small businesses shall submit an eligibility application in accordance with relevant provisions of 45 CFR §155.716.

Duration of Eligibility. A determination of an employer’s eligibility to participate in SHOP remains valid until the employer makes a change that could end its eligibility under 45 CFR §155.710(b), or until the employer withdraws from participation in the SHOP.

Eligible Employee.

(1)

Full-time common law employees are eligible for SHOP participation.

(2)

An employer who elects to cover part-time and seasonal employees working more than 120 days per year shall calculate full-time equivalency of the employee’s hours by:

(a)

Calculating the total number of hours worked by all part-time and seasonal employees per month; and

(b)

Dividing the total number of hours worked by 120.

Groups with Non-Common Law Employees. The following groups are eligible for SHOP participation if at least one common law full-time employee is also employed and elects to enroll in SHOP coverage:

(1)

A corporate partner;

(2)

An S corporation shareholder with more than 2 percent ownership;

(3)

A business that employs contractual 1099 employees; and

(4)

A sole proprietor.

Household Employers. A household employer is eligible for SHOP participation, under the following conditions:

(1)

Relevant eligibility requirements pursuant to this regulation are met; and

(2)

The employer has filed, or will file for the subsequent tax year, an appropriate Schedule H (Form 1040) or Form 941 demonstrating that a household employee is employed, and all appropriate taxes have been paid or withheld.

Minimum Participation. A qualified employer shall meet the following minimum participation requirements:

(1)

At least 60 percent minimum participation is required for qualified employers; and

(2)

Minimum participation is determined prior to initial plan enrollment, and annually prior to plan renewal.

Participation Determination. In applying a minimum participation requirement to determine whether the applicable percentage of participation is met, a carrier may not consider as eligible employees:

(1)

Employees who are enrolled in coverage through another group health plan, governmental coverage (such as Medicare, Medicaid, or TRICARE), coverage sold through the individual market, or other minimum essential coverage; or

(2)

Employees who are under the age of 26 years who are covered under their parent’s health benefit plan.

Waiver of Minimum Participation Period. Small employers that cannot comply with minimum participation requirements may apply for coverage during the period that begins on November 15 and extends through December 15 of any year.

Determination Outcomes.

(1)

A group shall be enrolled once it has been determined that the group satisfied the minimum participation requirement.

(2)

If a group becomes enrolled as the result of an error in computing participation level, enrollment shall continue until the end of the month following the month in which a termination notice is sent.

(3)

The determination of an employer’s eligibility to participate in the SHOP remains valid until the employer makes a change that ends or alters its eligibility, or the employer withdraws from participation in the SHOP.

Eligibility Redetermination.

(1)

The SHOP Exchange may request new eligibility applications from employers in order to conduct eligibility redetermination.

(2)

Requests shall be made by the SHOP Exchange no later than 60 prior to the employer’s renewal date.

Eligibility Adjustment Period. When information submitted on the SHOP single employer application is inconsistent with information collected from third-party data sources through the verification process or otherwise received by the SHOP Exchange, the SHOP Exchange shall:

(1)

Make a reasonable effort to identify and address any causes of typographical errors or clerical errors;

(2)

Notify the employer of the inconsistency;

(3)

Provide the employer with a period of 30 days from the date the notice is sent, to present satisfactory documentary evidence to support the employer’s application, or resolved the inconsistency; and

(4)

If after the 30-day period described in §N(3) of this regulation the SHOP Exchange has not received satisfactory documentary evidence:

(a)

Notify the employer of its denial or termination of eligibility and of the employer’s right to appeal such determination; and

(b)

If the employer was enrolled pending the confirmation or verification of eligibility information, discontinue the employer’s participation in the SHOP at the end of the month following the month in which the ineligibility notice is sent.

Employer Eligibility Appeal.

(1)

An employer has the right to appeal:

(a)

A notice of denial or termination of eligibility; and

(b)

A failure by the SHOP Exchange to provide a timely eligibility determination or a timely notice of an eligibility determination.

(2)

All appeals shall be requested within 90 days from the date of the notice of denial or termination of eligibility.

(3)

The SHOP Exchange shall provide a written notice of the right to appeal a denial of eligibility which includes:

(a)

The reason for the denial or termination of eligibility, including a citation to the applicable regulations; and

(b)

The procedure by which the employer may request an appeal of the denial or termination of eligibility.

(4)

The SHOP Exchange shall issue written notice of the appeal decision to the employer within 90 days of the date the appeal request is received.

(5)

If an employer is found eligible following the appeal decision, then, at the employer’s option, the effective date of coverage or enrollment through the SHOP Exchange under the decision is:

(a)

Retroactive to the effective date of coverage or enrollment through the SHOP Exchange that the employer would have had if the employer had been correctly determined eligible; or

(b)

Prospective to the first day of the month following the date of the notice of the appeal decision.

(6)

If the employer is found ineligible under the appeal decision, then the appeal decision is effective as of the date of the notice of the appeal decision.

Safe Harbor. The SHOP Exchange and participating carriers shall treat a qualified small business which ceases to be eligible solely by reason of an increase in the number of employees, as an eligible small business until it otherwise fails to meet the eligibility criteria of this section, or it elects to terminate coverage for qualified employees through the SHOP Exchange.

Reporting. Employers shall submit a new application within 30 days of any change made to the business structure that could alter its SHOP Exchange eligibility.

Regulation .04 Enrollment.Link Copy Citation

Rolling Enrollment Period. A qualified employer may purchase coverage for its small group at any point during the year.

Length of Plan Year. The employer’s plan year shall consist of the 12-month period beginning with the qualified employer’s effective date of coverage.

Effective Coverage Dates.

(1)

The effective date of coverage is:

(a)

No later than the first day of the following month for a group enrollment received on the first through the fifteenth day of any month; or

(b)

No later than the first day of the second following month for a group enrollment received on the sixteenth though the last day of any month.

(2)

A qualified employer may opt for a later effective date within a quarter for which small group market rates are available.

Newly Hired Employees.

(1)

The effective date of coverage for a qualified health plan selection received by the SHOP from a newly qualified employee is the first day of the month following the end of the waiting period.

(2)

If the newly qualified employee makes a plan selection on the first day of the month and any applicable waiting period has ended by that date, coverage shall be effective on that date.

Annual Open Enrollment Period Standards. A carrier shall establish an open enrollment period that meets the requirements established under Insurance Article, §§15-1208.1 and 15-1208.2, Annotated Code of Maryland.

Eligibility Requirement Waiver Period. If a small group health plan cannot comply with group participation rules for the offering of health insurance coverage, a carrier may restrict the availability of such coverage to an annual enrollment period that begins November 15 and extends through December 15 of each calendar year.

Special Enrollment Periods. Special enrollment periods shall be established in accordance with the requirements of Insurance Article, §§15-1208.1 and 15-1208.2, Annotated Code of Maryland.

Waiting Period.

(1)

A small employer may implement a waiting period of no more than 60 days for any qualified employee.

(2)

Coverage will be effective the first of the month following the end of the waiting period.

Payment of First Month’s Premium.

(1)

A small employer shall pay the first month’s premium to the carrier of the qualified health plan to effectuate enrollment when the small employer has:

(a)

Enrolled in a qualified health plan after coverage from a previous enrollment in a qualified health plan the individual had was terminated;

(b)

Enrolled for the first time in a qualified health plan in the SHOP Exchange; or

(c)

Enrolled in a qualified health plan offered by a different carrier of the same holding company in the SHOP Exchange.

(2)

The first month’s premium payment to effectuate prospective coverage for qualified health plan selections made during an annual open enrollment period or during a special enrollment period shall be due from the employer on a uniformly applied date specified by the authorized carrier of the qualified health plan that is no earlier than the coverage effective date but no later than 30 calendar days from the coverage effective date.

(3)

The first month’s premium payment to effectuate prospective coverage for qualified health plan selections made during a special enrollment period under §G of this regulation shall be due from the employer on a uniformly applied date specified by the authorized carrier of the qualified health plan that is no earlier than the coverage effective date but no later than 30 calendar days from the date the carrier receives the enrollment transaction from the SHOP.

(4)

Payment to effectuate retroactive coverage shall include the premium due from the employer for all months of retroactive coverage and the full premium amount of the first prospective month of coverage.

(5)

Payment to effectuate retroactive coverage for qualified health plan selections made during a special enrollment period shall be due on a uniformly applied date specified by the authorized carrier that is no earlier than the coverage effective date and no later than 30 calendar days from the date the carrier receives the enrollment transaction from the SHOP Exchange or the coverage effective date, whichever is later.

(6)

An authorized carrier may choose to extend the premium due date if the carrier does so in a uniform and consistent manner for all similarly situated applicants.

Group Installation.

(1)

A carrier shall install groups upon enrollment.

(2)

Employee choice groups shall be effective on the date the group first effectuated coverage.

Renewal. A health insurance issuer offering SHOP coverage shall renew or continue in force the coverage in the manner prescribed under Insurance Article, §15-1212, Annotated Code of Maryland.

Regulation .05 Termination, Cancellation, and Renewal of Qualified Health Plan.Link Copy Citation

Termination.

(1)

A qualified employer who participates in the SHOP and who terminates SHOP coverage terminates the enrollment of the employees enrolled in plans under the SHOP.

(2)

An employee who is the certificate holder of a qualified health plan purchased through the SHOP, who terminates enrollment in a qualified health plan also terminates the enrollment of the other enrollees in the employee’s household.

(3)

Each enrollee who is not the certificate holder may terminate enrollment in a qualified health plan without affecting the enrollment status of the employee’s household or each individual member of the employee’s household other than the enrollee.

(4)

A carrier shall process the SHOP Exchange’s termination determination promptly and without undue delay.

(5)

A carrier shall maintain records of termination of enrollment in a qualified health plan in the format specified by the SHOP Exchange in an electronic data interchange format for a period of 10 years.

(6)

(7)

A carrier shall send an electronic transaction to the SHOP Exchange documenting, or acknowledging, each termination of coverage carried out under this chapter, promptly and without undue delay.

Termination by the SHOP Exchange.

(1)

Termination Due to Failure to Pay.

(a)

If payment for a group is not received by the end of the grace period stated in the group contract, the SHOP Exchange may terminate the group’s coverage.

(b)

The last day of coverage shall be the last day of the grace period stated in the group contract or first day of the coverage month.

(2)

Termination Due to Error, Misconduct, Fraud, or Misrepresentation of a Group. Coverage may be retroactively terminated if:

(a)

The enrollment in a qualified health plan through the SHOP Exchange was unintentional, inadvertent, or erroneous and was the result of the error or misconduct of an officer, employee, or agent of the SHOP Exchange, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities;

(b)

The employee or group was enrolled in a qualified health plan without the employee or group’s knowledge or consent by any third party, including third parties who have no connection with the SHOP Exchange; or

(c)

The eligibility determination was made based on information regarding the group that is false or misrepresentative of the actual composition of the group.

(3)

Notification of Termination.

(a)

If any employee’s coverage or enrollment through the SHOP is terminated due to nonpayment of premiums or due to a loss of the employee’s eligibility to participate in the SHOP, including the coverage of an employee who loses eligibility because a qualified employer has lost its eligibility, the SHOP shall notify the employee of the termination.

(b)

Such notice of termination shall include the termination effective date and reason for termination, and shall be sent within 3 business days if an electronic notice is sent, and within 5 days if a mailed hard copy notice is sent.

Renewal, Nonrenewal, and Cancellation. Renewal, nonrenewal, and cancellation shall be conducted in accordance with the requirements of Insurance Article, §15-1212, Annotated Code of Maryland.

Regulation .06 Coverage Models.Link Copy Citation

Employer Choice Model Requirements. A qualified employer may elect to make available to qualified employees a choice of qualified health plans offered through the SHOP Exchange by:

(1)

A single issuer across all available coverage levels; or

(2)

One or more qualified health plans offered by a single issuer.

Employee Choice Model Requirements. A qualified employer may select two consecutive metal levels of coverage, and employees may choose any SHOP plan across all the insurance companies that offer plans at those metal levels.

Regulation .07 Employer Contribution.Link Copy Citation

An employer is not required to contribute to the qualified health plan premiums of its employees.

If an employer chooses to contribute to the qualified health plan premiums of its employees, the employer shall:

(1)

Select a reference plan on which the contributions will be based;?and

(2)

Make a contribution that is:

(a)

A fixed percentage of the premium of the reference plan, based on the coverage level selected by the qualified employee and the qualified employee’s job classification; or

(b)

A dollar amount that ensures that all of the qualified employer’s employees with the same coverage level and job classification would pay the same amount if they purchased the reference plan.

A reference plan selected under this regulation:

(1)

If under the employer choice model established under Regulation .06A of this chapter, shall be a qualified plan that is:

(a)

Offered by the carrier or insurance holding company system selected by the qualified employer; and

(b)

Among the qualified plans of the carrier or insurance holding company system selected by the qualified employer; or

(2)

If under the employee choice model established under Regulation .06B of this chapter, shall be a qualified plan offered by any carrier at the metal level selected by the qualified employer.

Regulation .08 Premium Rating.Link Copy Citation

Premium Rating.

(1)

The total premium charged to a small group shall be developed using a per-member rating method.

(2)

For each covered employee and their covered dependents, the premium shall be determined as follows:

(a)

For each adult age 21 and over, multiply the base rate by the applicable age and geographic area factors; and

(b)

For each covered child age 0—20, multiply the base rate of the oldest three children by the applicable age and geographic area factors.

Composite Billing.

(1)

Composite billing is available only under the employer choice model set forth in Regulation .06A of this chapter.

(2)

The SHOP Exchange will determine premiums under composite billing based on instructions issued by the Commissioner.

Chapter 19. State-Based Young Adult Health Insurance Subsidies Program

Regulation .01 Scope.Link Copy Citation

This chapter sets forth the structure, implementation, and eligibility standards for the State-Based Young Adult Health Insurance Subsidies Program, as required under Insurance Article, §31-117 Annotated Code of Maryland.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

“Enrollee” means a qualified individual who is enrolled in a qualified health plan through the Individual Exchange.

(2)

“Essential health benefit” has the meaning set forth in Insurance Article, §31-116(a), Annotated Code of Maryland, and 42 U.S.C. §18022(b).

(3)

(4)

“Program” means the State-Based Young Adult Health Insurance Subsidies Program.

Regulation .03 Eligibility Requirements for Subsidies Through the Program.Link Copy Citation

An enrollee is eligible to receive subsidies from the Program during a month if:

(1)

The enrollee is a member of a tax filer’s tax household and the tax filer has met the eligibility requirements for APTC in accordance with the requirements in COMAR 14.35.07.08A—C, E, and G;

(2)

The enrollee is a member of a tax filer’s tax household and the tax filer attests to a household income, as defined in 26 CFR §1.36B-1(e), greater than or equal to 138 percent but not more than 400 percent of the FPL for the benefit year for which coverage is requested;

(3)

The enrollee is at least 18 years old; and

(4)

The enrollee is under the age of 35 years.

Eligibility under this regulation is contingent upon verification of the enrollee’s attestation that the enrollee meets the criteria in §A of this regulation.

The enrollee’s age as of the effective date of coverage shall be used in determining the enrollee’s eligibility to receive subsidies from the Program.

In any calendar year of the program:

(1)

The Board may limit the availability of subsidies, regardless of eligibility, if the costs of the program are projected to exceed the budgeted allowance for that calendar year;

(2)

The limit described in §D(1) of this regulation may take the form of:

(a)

A limit on the number of enrollees eligible for the subsidy;

(b)

A limit on increases in subsidies during a plan year for enrollees after enrollment; or

(c)

Any other limit or combination of limits as the Board deems appropriate;

(3)

Any limit on the availability of subsidies for enrollees in the program shall be applied uniformly to all enrollees after the effective date of the Board’s decision; and

(4)

The Exchange shall monitor the data outlined in Regulation .05 of this chapter to determine, in consultation with the Maryland Insurance Administration, the recommended limits to the Program.

Effective Dates for Changes in Subsidy Eligibility.

(1)

Except as otherwise specified under this regulation, changes in eligibility for subsidies determined by the Individual Exchange are effective the first day of the month following the date on which the determination is made.

(2)

When an applicant is determined newly eligible for Medicaid or MCHP, the applicant shall be ineligible for subsidies beginning the first of the month after the enrollee is determined newly eligible for Medicaid or MCHP.

(3)

When an applicant is eligible for a special enrollment period under COMAR 14.35.07.12—.19, the applicant or enrollee shall be in accordance with the applicable effective date specified for each special enrollment period under COMAR 14.35.07.12—.19.

(4)

When an enrollee’s enrollment is terminated by the enrollee as set forth in 45 CFR §155.430(b)(1) or terminated by the Exchange under 45 CFR §155.430(b)(2)(i)—(vii) the applicant or enrollee shall be in accordance with the applicable effective date of the termination set forth in 45 CFR §155.430(d).

Regulation .04 Calculation of Subsidies Under the Program.Link Copy Citation

The subsidy may not exceed the enrolle’s premium amount.

The subsidy shall be calculated for eligible enrollees in a tax household and applied to the premium for each eligible enrollee.

The subsidy shall be applied to the premium balance remaining after application of the Advance Premium Tax Credit.

Basis of Calculation.

(1)

For enrollees with a greater than 0 percent premium contribution based on the payment parameters set by the Board, the subsidy shall be calculated based on, and applied only to, the portion of premium allocated to essential health benefits.

(2)

For enrollees with a 0 percent premium contribution based on the payment parameters set by the Board, the subsidy shall also be applied to nonessential health benefits so that the enrollee’s total premium responsibility is equal to $0.

For each benefit year after 2022, the Board shall set the payment parameters for the Program before December 31 of the calendar year preceding the applicable plan year.

Regulation .05 Exchange Data Collection, Reporting, and Maintenance.Link Copy Citation

The Exchange shall track data on the Program including:

(1)

On a monthly basis, or more frequently as required to appropriately monitor enrollment and spending under the program, the average number of young adults receiving subsidies under the Program;

(2)

On a monthly basis, or more frequently as required to appropriately monitor enrollment and spending under the program, the average subsidy amount received by young adults under the Program; and

(3)

The impact the Program has on rates in the individual insurance market.

Information tracked in §A of this regulation shall be posted monthly on the website of the Individual Exchange and included in the Annual Report required under Insurance Article, §31–119(d), Annotated Code of Maryland.

The Individual Exchange shall maintain documents and records relating to the Program, whether paper, electronic, or in other media, for each benefit year for at least 10 years.

The Individual Exchange shall ensure that the collection of personally identifiable information is limited to information reasonably necessary for use in the calculation of subsidies. Any use and disclosure of personally identifiable information shall be limited to those purposes for which the personally identifiable information was collected, including for purposes of data validation.

Regulation .06 Disbursement of Subsidies.Link Copy Citation

The Individual Exchange shall transmit subsidies directly to the carrier with whom the recipient is enrolled, to be applied to the recipient’s premium.

A carrier that receives notice from the Individual Exchange that an individual enrolled in the carrier’s QHP is eligible for subsidies shall:

(1)

Reduce the portion of the premium charged to or for the individual for the applicable month or months by the amount of the subsidy;

(2)

Notify the Exchange of the reduction in the portion of the premium charged to the individual in accordance with 45 CFR §156.265(g); and

(3)

Include with each billing statement, as applicable, to or for the individual the amount of the subsidy for the applicable month or months, and the remaining premium owed.

Refunds.

(1)

If a carrier discovers that it did not reduce the portion of the premium charged to or for an enrollee for the applicable month or months by the amount of the subsidy in accordance with §B(1) of this regulation, the carrier shall notify the enrollee of the improper reduction within 45 calendar days of the carrier’s discovery of the improper reduction and refund any excess premium paid by or for the enrollee.

(2)

Unless a refund is requested by or for the enrollee, the carrier shall, within 45 calendar days of discovery of the error, apply the excess premium paid by or for the enrollee to the enrollee’s portion of the premium or refund the amount directly.

(3)

If any excess premium remains after application of premium as described in §C(2) of this regulation:

(a)

The carrier shall apply the excess premium to the enrollee’s portion of the premium for each subsequent month for the remainder of the period of enrollment or benefit year until the excess is fully applied or refund the remaining amount directly; and

(b)

At the end of the period of enrollment or benefit year, the carrier shall refund any excess premium within 45 calendar days of the end of the period of enrollment or benefit year, whichever comes first.

(4)

If a refund is requested by or for the enrollee, the refund shall be provided within 45 calendar days of the date of the request.

A carrier may not refuse to commence coverage under a policy or terminate coverage on account of any delay in payment of a subsidy on behalf of an enrollee if the carrier has been notified by the Exchange that the carrier will receive such advance payment.

Carriers shall participate in the payment and reconciliation process established by the Individual Exchange to ensure that appropriate payments are received by the carriers and that excess payments are returned by the carriers to the Individual Exchange.

Regulation .07 Document Retention and Audits.Link Copy Citation

Carriers shall maintain documents and records, whether paper, electronic, or in other media, sufficient to substantiate the disbursement of subsidies made pursuant to Regulations .03 and .06 of this chapter for a period of at least 10 years and shall make those documents and records available upon request by the Board or its designee to any such entity for purposes of verification, investigation, audit, or other review of subsidy disbursement.

The Individual Exchange or its designee may audit a carrier offering subsidies through the program to assess its compliance with the requirements of this chapter. The carrier shall ensure that its relevant contractors, subcontractors, or agents cooperate with any audit under this section. If an audit results in a finding of material weakness or significant deficiency with respect to compliance with any requirement of these regulations, the carrier shall complete all of the following:

(1)

Within 30 calendar days of the issuance of the final audit report, provide a written corrective action plan to the Individual Exchange for approval;

(2)

Implement the corrective action plan; and

(3)

Provide to the Individual Exchange written documentation of the corrective actions once taken.

Chapter 20. Hearings by the Board of Trustees

Regulation .01 Scope.Link Copy Citation

In General. This chapter applies to hearings conducted by the Board of Trustees of the Maryland Health Benefit Exchange.

Determinations Entitled to Hearings. This chapter applies only to the appeal of an Exchange determination regarding:

(1)

The amount of State-based subsidy paid by the Exchange to carriers pursuant to COMAR 14.35.19;

(2)

Contested cases under COMAR 14.35.10 in which the Board has revoked delegation authority;

(3)

Rehearings held pursuant to COMAR 14.35.10.11E; and

(4)

Any other matter in which the Board has the authority to conduct hearings, and the Board has determined that a hearing is necessary.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

“Board” means the Maryland Health Benefit Exchange Board of Trustees.

(2)

“Board Secretary” means the Secretary for the Board of Trustees.

(3)

Contested Case.

(a)

“Contested case” has the meaning stated in State Government Article, §10-202(d), Annotated Code of Maryland.

(b)

“Contested case” includes a proceeding:

(i)

Arising out of a determination made by the Exchange;

(ii)

Regarding an authorization, certification, or permit issued by the Exchange; or

(iii)

Arising out of any act of or failure to act by the Exchange, involving an authorization or a certification issued by the Exchange, that aggrieves a person.

(c)

“Contested case” does not include any other quasi-legislative hearing.

(4)

Determination.

(a)

“Determination” means a decision by the Exchange that requires the Board to provide the opportunity for a hearing to a person aggrieved by the decision.

(b)

“Determination” includes:

(i)

A decision as to whether a person against whom an administrative complaint has been received violated a law, regulation, or order; and

(ii)

An order issued pursuant to the Board's authority.

(5)

“Exchange” means the Maryland Health Benefit Exchange.

(6)

“Executive Director” means the Executive Director of the Maryland Health Benefit Exchange, appointed pursuant to Insurance Article, §31-105, Annotated Code of Maryland.

(7)

“Maryland Health Benefit Exchange” has the meaning set forth under Insurance Article, §31-101(e), Annotated Code of Maryland.

(8)

“Office” means the Office of Administrative Hearings.

(9)

“Person” has the meaning set forth under COMAR 28.02.01.02B(12).

(10)

“Presiding officer” means the Board member selected by the board to conduct, manage, and oversee the hearing and the administrative matters of an appeal on behalf of the Board of Trustees of the Maryland Health Benefit Exchange.

Regulation .03 Request for Hearing—In General.Link Copy Citation

Scope. This regulation applies to all requests for a hearing permitted under Regulation .01B of this chapter.

Except as provided in §D of this regulation, a person aggrieved may request a hearing by submitting a written statement to the Board Chair, signed by the requesting person and containing the following information:

(1)

The action or nonaction of the Exchange causing the person requesting the hearing to be aggrieved;

(2)

The facts related to the incident or incidents about which the person requests the Board to act or not to act; and

(3)

The ultimate relief requested.

Hearing Requests—Timing.

(1)

Except as provided in §D of this regulation, a request for a hearing shall be received by the Board within 30 calendar days of the date of the letter notifying the party of the Exchange’s action, intention to act, or failure to act.

(2)

In calculating the 30-day period, the date of the letter notifying the party of the Exchange's action, intention to act, or failure to act is not included.

(3)

The end of a day is considered to be 11:59 p.m. Eastern Time.

(4)

The last day of the 30-day period is included unless it is a Saturday, Sunday, legal holiday, or day that the Maryland Health Benefit Exchange is closed for a part of the day.

(5)

If the last day of the 30-day period is a Saturday, Sunday, legal holiday, or a day that the Maryland Health Benefit Exchange is closed for a part of the day, the 30-day period runs until the end of the next day which is not a Saturday, Sunday, legal holiday, or day that the Maryland Health Benefit Exchange is closed for a part of the day.

(6)

Intermediate Saturdays, Sundays, legal holidays, and days that the Maryland Health Benefit Exchange is closed for a part of the day shall be counted toward the 30-day period.

Request for Hearing—Appeals of Procurement Bid Protests.

(1)

A person aggrieved may request a hearing under this subparagraph by submitting a written statement to the Board Chair postmarked within 10 calendar days after issuance of the decision resolving the protest, and containing the following information:

(a)

Each ground on which the protestor claims that the protest was resolved in error; and

(b)

A copy of the initial protest and the decision of the Executive Director or designated procurement officer resolving the protest

(2)

Ten copies of all required materials shall be submitted.

Except as provided in §F of this regulation, upon receipt of a proper request, the Board shall grant a hearing unless, in viewing the facts set forth by the person making the request, in the light most favorable to that person, the Board determines that:

(1)

The Board has no authority to take action;

(2)

The request does not contain the information required by this chapter;

(3)

The request is untimely; or

(4)

The request is moot.

For appeals of procurement bid protests, instead of granting a hearing, the Board may:

(1)

Resolve the appeal without granting a hearing;

(2)

Elect to refer the matter for a hearing and recommended decision to a single member of the Board; or

(3)

Elect to refer the matter for a hearing and recommended decision to a panel consisting of two or more members of the Board.

Regulation .04 Service of Notices, Decisions, Orders, and Other Documents.Link Copy Citation

The Board Secretary shall provide notice of a hearing pursuant to State Government Article, §10-209, Annotated Code of Maryland.

The notice shall state:

(1)

The date, time, place, and nature of the hearing;

(2)

The right to call witnesses and submit documents or other evidence under State Government Article, §10-213(f), Annotated Code of Maryland;

(3)

Any applicable right to request subpoenas for witnesses and evidence and specify the costs, if any, associated with such a request;

(4)

That a copy of the hearing procedure is available on request and specify the costs associated with such a request;

(5)

Any right or restriction pertaining to representation;

(6)

That failure to appear for the scheduled hearing may result in an adverse action against the party; and

(7)

That, unless otherwise prohibited by law, the parties may agree to the evidence and waive their right to appear at the hearing.

Notices, decisions, orders, and other documents issued by the Board may be served on a person by:

(1)

Personal delivery to the person;

(2)

Mailing a copy of the document, first class, postage prepaid, to the person's address of record on file with the Exchange;

(3)

Mailing a copy of the document, first class, postage prepaid, to the person's last known address if different from the person's address of record on file with the Exchange;

(4)

Mailing a copy of the document by certified mail to the person's address of record on file with the Exchange or last known address; or

(5)

Delivering or mailing a copy of the document, first class, postage prepaid, to the person's attorney, if the person is represented by counsel.

Notice of a hearing is sufficient if the initial notice of a hearing is sent by regular mail to a party at the party's business and resident addresses, as applicable, on file with the Exchange.

A hearing may be rescheduled if there is satisfactory showing that the notice was sent not less than 30 calendar days before the hearing, or upon agreement of all parties.

The Board shall maintain a record stating:

(1)

To whom the initial notice was sent;

(2)

The address to which the initial notice was sent;

(3)

The date the initial notice was sent;

(4)

The manner of service; and

(5)

The name of the person who sent the initial notice.

Regulation .05 Discovery.Link Copy Citation

By written request served on other parties and filed with the presiding officer not later than 30 calendar days before the scheduled hearing, a party may require any other party to produce, within 15 calendar days, for inspection or copying, any file, memorandum, correspondence, document, object, or tangible item:

(1)

Relevant to the subject matter of the case; and

(2)

Not privileged.

Unless provided by agreement of the parties, no other discovery procedure is allowed.

Copies.

(1)

Copies of requested documents and records shall be made at the expense of the party making the request.

(2)

The charge for copies of requested documents and records may be waived by the custodian of the documents in accordance with State Government Article, §10-621(e), Annotated Code of Maryland, or other applicable law.

Objection to Production.

(1)

A party may object to the production of a file, memorandum, correspondence, document, object, or tangible item by filing a motion to quash discovery or for other relief.

(2)

The presiding officer, for cause shown, may issue any order that justice requires to protect the party from annoyance, embarrassment, oppression, or undue burden or expense.

A party who has responded to a request for production and who obtains or discovers, before the hearing, additional files, memoranda, correspondence, documents, objects, or tangible things that are relevant to the request for production shall supplement the response to the request promptly.

If a party fails to comply with a request for production, the presiding officer, either on the presiding officer's own motion or by motion of the party requesting the production, may issue an order:

(1)

Refusing to allow the party to support or oppose designated claims or defenses;

(2)

Prohibiting the party from introducing designated matters into evidence;

(3)

Striking any allegations or charges made by the party failing to produce;

(4)

Staying further proceedings until the discovery is provided; or

(5)

Dismissing the action or any part of it.

Regulation .06 Subpoenas.Link Copy Citation

On request of a party, the presiding officer may issue subpoenas requiring the attendance and testimony of witnesses and the production, at the hearing, of any tangible items in the possession or under the control of a witness.

Subpoena Requests.

(1)

A request for a subpoena shall:

(a)

Be made, in writing, to the Board Chair; and

(b)

Specify the:

(i)

Name and full address of the person to be subpoenaed; and

(ii)

Name, full address, and telephone number of the party requesting the subpoena.

(2)

A subpoena that requests the production of tangible items, books, papers, or other documents shall describe those items with particularity.

(3)

A subpoena request need not be served on all parties.

Service of Subpoenas.

(1)

Except as provided in §C(2) of this regulation, subpoenas shall be served by hand delivery by an individual 18 years old or older who is not a party to the proceeding. For subpoenas requested 15 calendar days or less before the scheduled hearing, the requester shall provide service.

(2)

In a case where the individual to be served resides outside Maryland, the subpoena may be served by certified mail.

Return of service shall be made by:

(1)

Affidavit, if hand delivered; or

(2)

Return receipt, if mailed.

A person may object to a subpoena by filing a motion to quash or for other relief.

If a request for a subpoena was filed less than 15 calendar days before the hearing date, the presiding officer may refuse to postpone the hearing based on the party's inability to serve the subpoena.

Regulation .07 Conduct of Hearing—In General.Link Copy Citation

A hearing conducted under this chapter shall be audio recorded and presided over by a quorum of the Board.

The presiding officer will determine whether a hearing will be open to the public, unless otherwise required by law.

Parties to Proceeding.

(1)

The necessary parties to a contested case proceeding or other matter for which a hearing is being held are:

(a)

The Exchange; and

(b)

A person who requests a hearing due to being aggrieved by:

(i)

A determination made by the Exchange; or

(ii)

Any other act of or failure to act by the Exchange, involving an authorization or a certification issued by the Exchange.

(2)

Not later than 15 calendar days before the earlier of the prehearing conference or the hearing date, a person who is not a necessary party under §C(1) of this regulation may seek to become a party by intervention by filing a motion to intervene, which shall state:

(a)

The basis for considering intervention to be timely; and

(b)

How the financial interests of the person will be directly and immediately affected by an order of the Board resulting from the hearing.

The presiding officer shall conduct the hearing and may allow the case to proceed in a manner necessary to ensure the fair resolution of the issues, including, but not limited to, placing reasonable limitations on the number of witnesses a party may call and the exclusion of evidence which is repetitive, irrelevant, immaterial, or otherwise not probative. The Maryland Rules of Civil Procedure may be used as a guide for resolving procedural issues regarding the conduct of the hearing.

The presiding officer shall rule on all procedural matters, including motions, objections, and offers of proof.

The Board may designate an attorney to represent the Exchange. Once the hearing is closed by the presiding officer, the individual presenting the case on behalf of the Exchange may not have a further role in the decision process of the Exchange.

Motion for Summary Decision.

(1)

A party may move for summary decision at any time on any appropriate issue in the case.

(2)

The Board may grant a final summary decision if the Board finds that:

(a)

There is no genuine issue of material fact; and

(b)

A party is entitled to prevail as a matter of law.

Motion to Dismiss. Upon motion, the Board may issue a final decision dismissing an initial pleading which fails to state a claim for which relief may be granted.

Motion for Judgment.

(1)

A party may move for judgment on any or all of the issues in any action at the close of the evidence offered by an opposing party. The moving party shall state all reasons why the motion should be granted. No objection to the motion for judgment shall be necessary. A party does not waive the right to make the motion by introducing evidence during the presentation of any opposing party's case.

(2)

When a party moves for judgment at the close of the evidence offered by an opposing party, the Board may:

(a)

Proceed to determine the facts and to render judgment against an opposing party; or

(b)

Decline to render judgment until the close of all evidence.

(3)

A party who moves for judgment at the close of the evidence offered by an opposing party may offer evidence if the motion is not granted, without having reserved the right to do so and to the same extent as if the motion had not been made. In so doing, the party withdraws the motion.

Regulation .08 Postponements.Link Copy Citation

At the discretion of the presiding officer, a hearing may be postponed if a written request for postponement is filed with the presiding officer not later than 15 calendar days before the date of the hearing.

A hearing may not be postponed, except for good cause, when the request for postponement is filed within 15 calendar days of the date of the hearing.

Regulation .09 Default Orders.Link Copy Citation

The presiding officer may issue a default order against a party other than the Exchange that, after receiving proper notice, fails to appear at a hearing if:

(1)

Notice is issued by the Board, and the party failing to appear is the person against whom the notice was issued; or

(2)

In any other contested case hearing, the party failing to appear is the person that requested the hearing.

In a hearing arising out of a notice or determination issued by the Exchange, the default order shall:

(1)

State the facts supporting the finding of proper notice to the person against whom the notice or determination was issued;

(2)

Adopt the facts and violations of law as alleged by the Exchange in its notice or determination as if by admission of the person against whom the charging document, order, or notice was issued; and

(3)

Adopt the sanction requested by the Exchange.

The Board Secretary shall serve the default order directly on the parties by certified mail.

Within 15 calendar days after service of a default order, the party in default may submit to the Board a written motion:

(1)

Requesting that the default order be vacated or modified; and

(2)

Stating the grounds for the request.

If the presiding officer finds that there is:

(1)

Good cause to excuse the default, the presiding officer may:

(a)

Vacate or modify the default order; and

(b)

Schedule the case for further appropriate proceedings; or

(2)

No good cause to excuse the default, the presiding officer shall:

(a)

Deny the motion; and

(b)

Affirm the default order as the final order.

Regulation .10 Decisions.Link Copy Citation

The presiding officer shall:

(1)

Sign the final order following a hearing; and

(2)

File a copy of the final order with the Exchange and serve a copy on all parties to the hearing.

The final order is effective when issued, unless a different date is specified in the decision.

The decision of the Board is the final administrative decision of the case.

Regulation .11 Mistake or Error in the Final Order.Link Copy Citation

The Board may correct an order if, upon review, the final order was issued as a result of fraud, mistake, or inadvertence or contains a clerical error.

Regulation .12 Judicial Review.Link Copy Citation

A party adversely affected by a final decision of the Board may obtain judicial review of the decision as provided by law.

Chapter 21. State-Based Health Insurance Subsidies Program

Regulation .01 Scope.Link Copy Citation

This chapter sets forth the structure, implementation, and eligibility standards for the State-Based Health Insurance Subsidies Program, as required under Insurance Article, §31-117, Annotated Code of Maryland.

If the advance premium tax credits under 26 U.S.C. §36B(b)(3)(A)(iii) are extended for calendar years 2026 and 2027, the subsidy under this chapter shall be abrogated and of no further force and effect.

Regulation .02 Definitions.Link Copy Citation

In this chapter, the following terms have the meanings indicated.

Terms Defined.

(1)

“Enrollee” means a qualified individual who is enrolled in a qualified health plan through the Individual Exchange.

(2)

“Essential health benefit” has the meaning set forth in Insurance Article, §31-116(a), Annotated Code of Maryland, and 42 U.S.C. §18022(b).

(3)

“Federal poverty level (FPL)” means the most recently published federal poverty level guidelines, updated periodically in the Federal Register by the Secretary of HHS as set forth in 42 U.S.C. §9902(2), as of the first day of the open enrollment period for qualified health plans (QHPs) offered through the Individual Exchange for a calendar year.

(4)

“Program” means the State-Based Health Insurance Subsidies Program.

Regulation .03 Eligibility Requirements for Subsidies Through the Program.Link Copy Citation

An enrollee is eligible to receive subsidies from the Program during a month if:

(1)

The enrollee is a member of a tax filer’s tax household and the tax filer has met the eligibility requirements for APTC in accordance with the requirements in COMAR 14.35.07.08A(2), B— C, E, F and H; and

(2)

The enrollee experiences an increase in the applicable percentages established under 26 U.S.C. §36B(B)(3)(A)(iii) for premiums based on household income in calendar years 2026 and 2027, as compared to the applicable percentages in place for calendar year 2025.

The subsidy shall be automatically applied to eligible enrollees’ premiums.

In any calendar year of the program:

(1)

The Board may limit the availability of subsidies, regardless of eligibility, if the costs of the program are projected to exceed the budgeted allowance for that calendar year;

(2)

The limit described in §C(1) of this regulation may take the form of:

(a)

A limit on the number of enrollees eligible for the subsidy;

(b)

A limit on increases in subsidies during a plan year for enrollees after enrollment; or

(c)

Any other limit or combination of limits as the Board deems appropriate;

(3)

Any limit on the availability of subsidies for enrollees in the program shall be applied uniformly to all enrollees after the effective date of the Board’s decision; and

(4)

The Exchange shall monitor the data outlined in Regulation .05 of this chapter to determine, in consultation with the Maryland Insurance Administration, the recommended limits to the Program.

Effective Dates for Changes in Subsidy Eligibility.

(1)

(2)

(3)

When an applicant is eligible for a special enrollment period under COMAR 14.35.07.12—.19, the applicant or enrollee shall be determined eligible for subsidies as of the applicable effective date specified for each special enrollment period under COMAR 14.35.07.12—.19.

(4)

When an enrollee’s enrollment is terminated by the enrollee as set forth in 45 CFR §155.430(b)(1) or terminated by the Exchange under 45 CFR §155.430(b)(2)(i)—(vii) the subsidy shall be terminated in accordance with the applicable effective date of the termination set forth in 45 CFR §155.430(d).

Regulation .04 Calculation of Subsidies Under the Program.Link Copy Citation

The subsidy may not exceed the enrollee’s premium amount.

The subsidy shall be applied to the premium balance remaining after application of the Advance Premium Tax Credit.

Basis of Calculation.

(1)

(2)

For plan years 2026 and 2027, the Board shall set the payment parameters for each plan year of the Program before December 31 preceding the applicable plan year.

Regulation .05 Exchange Data Collection, Reporting, and Maintenance.Link Copy Citation

The Exchange shall track data on the Program including:

(1)

On a monthly basis, or more frequently as required to appropriately monitor enrollment and spending under the program, the average number of enrollees receiving subsidies under the Program;

(2)

On a monthly basis, or more frequently as required to appropriately monitor enrollment and spending under the program, the average subsidy amount received by enrollees under the Program; and

(3)

The impact the Program has on rates in the individual insurance market.

Information tracked in §A(1) and (2) of this regulation shall be posted on the website of the Individual Exchange and included in the Annual Report required under Insurance Article, §31-119(d), Annotated Code of Maryland.

The Individual Exchange shall maintain documents and records relating to the Program, whether paper, electronic, or in other media, for each benefit year for at least 10 years.

Regulation .06 Disbursement of Subsidies.Link Copy Citation

The Individual Exchange shall transmit subsidies directly to the carrier with whom the recipient is enrolled, to be applied to the recipient’s premium.

A carrier that receives notice from the Individual Exchange that an individual enrolled in the carrier’s QHP is eligible for subsidies shall:

(1)

Reduce the portion of the premium charged to or for the individual for the applicable month or months by the amount of the subsidy;

(2)

Notify the Exchange of the reduction in the portion of the premium charged to the individual in accordance with 45 CFR §156.265(g); and

(3)

Include with each billing statement, as applicable, to or for the individual the amount of the subsidy for the applicable month or months, and the remaining premium owed.

Failure to Timely Report Effectuations.

(1)

The Individual Exchange requires carriers to send 834 effectuation files to the Individual Exchange in a timely manner, and not more than 90 days after receiving an 834 enrollment file for a recipient.

(2)

Notwithstanding §A of this regulation, if a carrier sends an 834 effectuation file to the Individual Exchange more than 90 days after the coverage start date on the 834 enrollment file sent by the Individual Exchange to the carrier, the Individual Exchange will transmit subsidies to a carrier for a maximum of 3 months retroactively, including the month in which the effectuation file is transmitted to the Individual Exchange as one of the 3 retroactive months.

(3)

An individual enrolled in a carrier’s QHP shall be held harmless for any portion of premium not transmitted to the carrier under § C(2) of this regulation.

Refunds.

(1)

(2)

Unless a refund is requested by or for the enrollee, the carrier shall, within 45 calendar days of discovery of the error, either apply the excess premium paid by or for the enrollee to the enrollee’s portion of the premium or refund the amount directly.

(3)

If any excess premium remains after application of premium as described in §C(2) of this regulation:

(a)

(b)

(4)

If a refund is requested by or for the enrollee, the refund shall be provided within 45 calendar days of the date of the request.

A carrier may not refuse to commence coverage under a policy or terminate coverage on account of any delay of advance payment of a subsidy on behalf of an enrollee if the carrier has been notified by the Exchange that the carrier will receive such advance payment.

Regulation .07 Document Retention and Audits.Link Copy Citation

Carriers shall maintain documents and records, whether paper, electronic, or in other media, sufficient to substantiate the disbursement of subsidies made pursuant to Regulations .03 and .06 of this chapter for a period of at least 10 years and shall timely make those documents and records available upon request by the Board or its designee to any such entity for purposes of verification, investigation, audit, or other review of subsidy disbursement.

Audits.

(1)

The Individual Exchange may require a carrier offering subsidies through the program to participate in an audit to assess its compliance with the requirements of this chapter. For any audit under this section, the Individual Exchange shall determine whether the audit shall be conducted by:

(a)

The Individual Exchange,

(b)

A designee of the Individual Exchange; or

(c)

An independent, third-party auditor compensated by the carrier.

(2)

Timeliness of Audit Reports.

(a)

If the audit is conducted by an independent, third-party auditor as specified in §B(1)(c) of this regulation, the carrier must obtain the results no later than 6 months after an audit is requested by the Individual Exchange.

(b)

If the audit is conducted by an independent, third-party auditor as specified in §B(1)(c) of this regulation, the carrier shall send the audit report to the Individual Exchange within 15 days of receipt of the audit report by the carrier.

(3)

The carrier shall ensure that its relevant contractors, subcontractors, or agents cooperate with any audit under this section. If an audit results in a finding of material weakness or significant deficiency with respect to compliance with any requirement of these regulations, the carrier shall complete all of the following:

(a)

Within 30 calendar days of the issuance of the final audit report, provide a written corrective action plan to the Individual Exchange for approval;

(b)

Implement the corrective action plan; and

(c)

Provide to the Individual Exchange written documentation of the corrective actions once taken.

Title 14 — Subtitle 35. Maryland Health Benefit Exchange

Chapter 01. General Provisions

Regulation .01 Compliance with Federal Law.LinkCopy Citation

Regulation .02 Definitions.LinkCopy Citation

Chapter 02. Individual Exchange Navigator Certification and Training Standards

Regulation .01 Scope.LinkCopy Citation

Regulation .02 Eligibility Requirements.LinkCopy Citation

Regulation .03 Application Procedures.LinkCopy Citation

Regulation .04 Training Standards.LinkCopy Citation

Chapter 03. Individual Exchange Navigator Certification — Renewal, Reinstatement, Deactivation, and Suspension or Revocation of Certification

Regulation .01 Term.LinkCopy Citation

Regulation .02 Renewal.LinkCopy Citation

Regulation .03 Reinstatement.LinkCopy Citation

Regulation .04 Inactive Certification.LinkCopy Citation

Regulation .05 Suspension or Revocation.LinkCopy Citation

Chapter 04. Insurance Producer Authorization to Sell Qualified Plans in the SHOP Exchange and Individual Exchange

Regulation .01 Scope.LinkCopy Citation

Regulation .02 Eligibility Requirements.LinkCopy Citation

Regulation .03 Application Procedures.LinkCopy Citation

Regulation .04 Training.LinkCopy Citation

Chapter 05. Insurance Producer Authorization — Renewal, Reinstatement, and Suspension or Revocation of Authorization

Regulation .01 Term.LinkCopy Citation

Regulation .02 Renewal.LinkCopy Citation

Regulation .03 Reinstatement.LinkCopy Citation

Regulation .04 Suspension or Revocation.LinkCopy Citation

Chapter 06. Exchange Consumer Services Center

Regulation .01 Exchange Call Center.LinkCopy Citation

Chapter 07. Eligibility Standards for Enrollment in a Qualified Health Plan, Eligibility Standards for APTC and CSR, and Eligibility Standards for Enrollment in a Catastrophic Qualified Health Plan in the Individual Exchange

Regulation .01 Scope.LinkCopy Citation

Regulation .02 Definitions.LinkCopy Citation

Regulation .03 Applying for Coverage Through the Individual Exchange.LinkCopy Citation

Regulation .04 Notice Requirements.LinkCopy Citation

Regulation .05 Eligibility Requirements for Enrollment in a Qualified Health Plan Through the Individual Exchange.LinkCopy Citation

Regulation .06 General Eligibility Requirements — Citizenship and Immigration Status.LinkCopy Citation

Regulation .07 General Eligibility Requirements — Residency in Individual Exchange Service Area.LinkCopy Citation

Regulation .08 Eligibility Requirements for Advance Payments of the Premium Tax Credit.LinkCopy Citation

Regulation .09 Eligibility Requirements for Cost — Sharing Reductions.LinkCopy Citation

Regulation .10 Eligibility Requirements for Enrollment in a Catastrophic Plan.LinkCopy Citation

Regulation .11 Enrollment in a QHP or Insurance Affordability Program Through the Individual Exchange.LinkCopy Citation

Regulation .12 Special Enrollment Periods — Loss of Minimum Essential Coverage or Termination of Other Specified Coverage Through the Individual Exchange.LinkCopy Citation

Regulation .13 Special Enrollment Periods — Change in Family Status Through the Individual Exchange.LinkCopy Citation

Regulation .14 Special Enrollment Period — Error, Misrepresentation, or Inaction through the Individual Exchange.LinkCopy Citation

Regulation .15 Special Enrollment Period — Misconduct Through the Individual Exchange.LinkCopy Citation

Regulation .16 Special Enrollment Period — Violation of Material Provision Through the Individual Exchange.LinkCopy Citation

Regulation .17 Special Enrollment Period — Exceptional Circumstances Through the Individual Exchange.LinkCopy Citation

Regulation .18 Special Enrollment Period — Permanent Move.LinkCopy Citation

Regulation .19 Special Enrollment Period — Other.LinkCopy Citation

Regulation .20 Exemptions.LinkCopy Citation

Regulation .21 Authorized Representative.LinkCopy Citation

Regulation .22 Medicaid to Private Plan Enrollment Program.LinkCopy Citation

Regulation .23 QHP Re-Enrollments—In General.LinkCopy Citation

Chapter 08. Captive Producer Training and Authorization Standards

Chapter 09. Consolidated Service Center Employee Training and Permit Standards

Regulation .01 Scope.LinkCopy Citation

Regulation .02 Definitions.LinkCopy Citation

Regulation .03 Eligibility Requirements.LinkCopy Citation

Regulation .04 Application Procedures.LinkCopy Citation

Regulation .05 Training Requirements.LinkCopy Citation

Regulation .06 General Permit Requirements.LinkCopy Citation

Chapter 10. Appeals from Determinations Regarding Producer Authorization or Individual Exchange Navigator Certification

Regulation .01 Scope.LinkCopy Citation

Regulation .02 Definitions.LinkCopy Citation

Regulation .03 Request for Hearing — In General.LinkCopy Citation

Regulation .04 Delegation of Authority.LinkCopy Citation

Regulation .05 Service of Notices, Decisions, Orders, and Other Documents.LinkCopy Citation

Regulation .06 Default Orders.LinkCopy Citation

Regulation .07 Administrative Decisions.LinkCopy Citation

Regulation .08 Exceptions.LinkCopy Citation

Regulation .09 Final Order Following Proposed Decision.LinkCopy Citation

Regulation .10 Decisions.LinkCopy Citation

Regulation .11 Mistake or Error in the Final Order.LinkCopy Citation

Regulation .12 Judicial Review.LinkCopy Citation

Chapter 11. Fair Hearings of Individual Exchange Eligibility Determinations

Regulation .01 Scope.LinkCopy Citation

Regulation .02 Definitions.LinkCopy Citation

Regulation .03 Opportunity for a Fair Hearing.LinkCopy Citation

Regulation .04 Notification of Right to Request a Fair Hearing.LinkCopy Citation

Regulation .05 Request for Fair Hearing.LinkCopy Citation

Regulation .06 Prehearing Procedures.LinkCopy Citation

Regulation .07 Hearing Procedures.LinkCopy Citation

Regulation .01 Compliance with Federal Law.Link Copy Citation

Regulation .02 Definitions.Link Copy Citation

Regulation .01 Scope.Link Copy Citation

Regulation .02 Eligibility Requirements.Link Copy Citation

Regulation .03 Application Procedures.Link Copy Citation

Regulation .04 Training Standards.Link Copy Citation

Regulation .01 Term.Link Copy Citation

Regulation .02 Renewal.Link Copy Citation

Regulation .03 Reinstatement.Link Copy Citation

Regulation .04 Inactive Certification.Link Copy Citation

Regulation .05 Suspension or Revocation.Link Copy Citation

Regulation .01 Scope.Link Copy Citation

Regulation .02 Eligibility Requirements.Link Copy Citation

Regulation .03 Application Procedures.Link Copy Citation

Regulation .04 Training.Link Copy Citation

Regulation .01 Term.Link Copy Citation

Regulation .02 Renewal.Link Copy Citation

Regulation .03 Reinstatement.Link Copy Citation

Regulation .04 Suspension or Revocation.Link Copy Citation

Regulation .01 Exchange Call Center.Link Copy Citation

Regulation .01 Scope.Link Copy Citation

Regulation .02 Definitions.Link Copy Citation

Regulation .03 Applying for Coverage Through the Individual Exchange.Link Copy Citation

Regulation .04 Notice Requirements.Link Copy Citation

Regulation .05 Eligibility Requirements for Enrollment in a Qualified Health Plan Through the Individual Exchange.Link Copy Citation

Regulation .06 General Eligibility Requirements — Citizenship and Immigration Status.Link Copy Citation

Regulation .07 General Eligibility Requirements — Residency in Individual Exchange Service Area.Link Copy Citation

Regulation .08 Eligibility Requirements for Advance Payments of the Premium Tax Credit.Link Copy Citation

Regulation .09 Eligibility Requirements for Cost — Sharing Reductions.Link Copy Citation

Regulation .10 Eligibility Requirements for Enrollment in a Catastrophic Plan.Link Copy Citation

Regulation .11 Enrollment in a QHP or Insurance Affordability Program Through the Individual Exchange.Link Copy Citation

Regulation .12 Special Enrollment Periods — Loss of Minimum Essential Coverage or Termination of Other Specified Coverage Through the Individual Exchange.Link Copy Citation

Regulation .13 Special Enrollment Periods — Change in Family Status Through the Individual Exchange.Link Copy Citation

Regulation .14 Special Enrollment Period — Error, Misrepresentation, or Inaction through the Individual Exchange.Link Copy Citation

Regulation .15 Special Enrollment Period — Misconduct Through the Individual Exchange.Link Copy Citation

Regulation .16 Special Enrollment Period — Violation of Material Provision Through the Individual Exchange.Link Copy Citation

Regulation .17 Special Enrollment Period — Exceptional Circumstances Through the Individual Exchange.Link Copy Citation

Regulation .18 Special Enrollment Period — Permanent Move.Link Copy Citation

Regulation .19 Special Enrollment Period — Other.Link Copy Citation

Regulation .20 Exemptions.Link Copy Citation

Regulation .21 Authorized Representative.Link Copy Citation

Regulation .22 Medicaid to Private Plan Enrollment Program.Link Copy Citation

Regulation .23 QHP Re-Enrollments—In General.Link Copy Citation

Regulation .01 Scope.Link Copy Citation

Regulation .02 Definitions.Link Copy Citation

Regulation .03 Eligibility Requirements.Link Copy Citation

Regulation .04 Application Procedures.Link Copy Citation

Regulation .05 Training Requirements.Link Copy Citation

Regulation .06 General Permit Requirements.Link Copy Citation

Regulation .01 Scope.Link Copy Citation

Regulation .02 Definitions.Link Copy Citation

Regulation .03 Request for Hearing — In General.Link Copy Citation

Regulation .04 Delegation of Authority.Link Copy Citation

Regulation .05 Service of Notices, Decisions, Orders, and Other Documents.Link Copy Citation

Regulation .06 Default Orders.Link Copy Citation

Regulation .07 Administrative Decisions.Link Copy Citation

Regulation .08 Exceptions.Link Copy Citation

Regulation .09 Final Order Following Proposed Decision.Link Copy Citation

Regulation .10 Decisions.Link Copy Citation

Regulation .11 Mistake or Error in the Final Order.Link Copy Citation

Regulation .12 Judicial Review.Link Copy Citation

Regulation .01 Scope.Link Copy Citation

Regulation .02 Definitions.Link Copy Citation

Regulation .03 Opportunity for a Fair Hearing.Link Copy Citation

Regulation .04 Notification of Right to Request a Fair Hearing.Link Copy Citation

Regulation .05 Request for Fair Hearing.Link Copy Citation

Regulation .06 Prehearing Procedures.Link Copy Citation

Regulation .07 Hearing Procedures.Link Copy Citation

Regulation .08 The Record.Link Copy Citation

Regulation .09 Findings, Timing of Decision, and Effect of Decision.Link Copy Citation

Regulation .10 Confidentiality.Link Copy Citation

Regulation .11 Program Benefits During Appeals Process.Link Copy Citation

Regulation .12 Eligibility for Enrollment in a Qualified Health Plan, for Advance Payments of Premium Tax Credit, for Cost-Sharing Reductions, and for the State-Based Young Adult Health Insurance Subsidies Program Pending Appeal.Link Copy Citation

Regulation .13 Applicability of Regulations.Link Copy Citation

Regulation .14 Authorized Representatives.Link Copy Citation

Regulation .01 Scope.Link Copy Citation

Regulation .02 Definitions.Link Copy Citation

Regulation .03 Eligibility Requirements.Link Copy Citation

Regulation .04 Scope of Authority.Link Copy Citation

Regulation .05 Application Procedures.Link Copy Citation