# COMAR Title 14 — Independent Agencies ## Subtitle 35 — Maryland Health Benefit Exchange ### 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 **Authority:** Insurance Article, §31-106(c)(1)(iv), Annotated Code of Maryland **Administrative History:** Effective date: April 15, 2013 (40:7 Md. R. 612) **Administrative History:** Regulation .01 repealed and new Regulations .01—.21 adopted effective March 11, 2019 (46:5 Md. R. 307) **Administrative History:** Regulation .02B amended effective November 29, 2021 (48:24 Md. R. 1025) **Administrative History:** Regulation .08 amended effective February 19, 2024 (51:3 Md. R.154) **Administrative History:** Regulation .08E amended effective February 17, 2025 (52:3 Md. R. 160) **Administrative History:** Regulation .11B, D amended effective June 13, 2022 (49:12 Md. R. 642) **Administrative History:** Regulation .11F amended effective February 17, 2025 (52:3 Md. R. 160) **Administrative History:** Regulation .12 amended effective June 13, 2022 (49:12 Md. R. 642) **Administrative History:** Regulation .12E amended effective February 17, 2025 (52:3 Md. R. 160) **Administrative History:** Regulation .12E, F amended effective February 19, 2024 (51:3 Md. R.154) **Administrative History:** Regulation .13B, E amended effective June 13, 2022 (49:12 Md. R. 642) **Administrative History:** Regulation .13E amended effective February 17, 2025 (52:3 Md. R. 160) **Administrative History:** Regulation .14E amended effective February 19, 2024 (51:3 Md. R.154) **Administrative History:** Regulation .14G adopted effective February 19, 2024 (51:3 Md. R.154) **Administrative History:** Regulation .18A, D amended effective June 13, 2022 (49:12 Md. R. 642) **Administrative History:** Regulation .18D amended effective February 17, 2025 (52:3 Md. R. 160) **Administrative History:** Regulation .19 amended effective June 13, 2022 (49:12 Md. R. 642) **Administrative History:** Regulation .19M, O amended effective February 17, 2025 (52:3 Md. R. 160) **Administrative History:** Regulation .19 N amended effective February 19, 2024 (51:3 Md. R.154) **Administrative History:** Regulation .22 adopted as an emergency provision effective May 10, 2023 (50:11 Md. R. 444); adopted permanently effective October 16, 2023 (50:20 Md. R. 889) **Administrative History:** Regulation .23 adopted effective August 5, 2024 (51:15 Md. R. 710) #### Regulation .01 Scope. *COMAR 14.35.07.01* 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. *COMAR 14.35.07.02* A. In this chapter, the following terms have the meanings indicated. B. 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. *COMAR 14.35.07.03* A. 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. B. 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. C. 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. D. 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. E. An individual who applies for an insurance affordability program shall receive an eligibility determination for all of the insurance affordability programs. F. An individual may submit an application to the Individual Exchange and receive an eligibility determination at any time during the year. G. 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. H. An individual shall complete and submit an application to enroll in coverage through the Exchange. #### Regulation .04 Notice Requirements. *COMAR 14.35.07.04* A. 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. B. 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. C. 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. D. 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. E. 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. F. 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. G. 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. H. 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. *COMAR 14.35.07.05* A. 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. B. 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. C. 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. *COMAR 14.35.07.06* 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. 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; B. A naturalized United States citizen; or C. A national from American Samoa or Swain's Island. #### Regulation .07 General Eligibility Requirements — Residency in Individual Exchange Service Area. *COMAR 14.35.07.07* A. 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. B. 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. C. 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. D. 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. E. 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. F. The service area of the Individual Exchange is Maryland. #### Regulation .08 Eligibility Requirements for Advance Payments of the Premium Tax Credit. *COMAR 14.35.07.08* A. 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). B. 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. C. 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. D. 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. E. 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. F. 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. G. APTC shall be calculated in accordance 26 CFR §1.36B-3. H. 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. I. An enrollee may accept less than the full amount of the APTC for which the enrollee is determined eligible. J. 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). K. 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. *COMAR 14.35.07.09* A. 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. B. 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. C. 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. D. 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. E. 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. F. 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. G. 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. *COMAR 14.35.07.10* A. 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. B. 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. C. Changes in enrollment in a catastrophic plan under this regulation are effective based on the effective dates under Regulation .08I of this chapter. 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 .11 Enrollment in a QHP or Insurance Affordability Program Through the Individual Exchange. *COMAR 14.35.07.11* A. 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. B. 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. C. 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. D. 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. E. 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. F. 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. G. 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). H. An authorized carrier shall accept and process an enrollment for a qualified individual that does not include a Social Security number. I. 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. *COMAR 14.35.07.12* A. 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. B. 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 under circumstances including, but not limited to: (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. C. 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. D. 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. E. 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. F. 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. G. 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. H. 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. *COMAR 14.35.07.13* A. 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. B. 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. C. Family status changes shall be determined in accordance with the law of the state where the change in family status occurred. D. 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. E. 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. *COMAR 14.35.07.14* A. 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. B. 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. C. 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. D. 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. E. 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. F. 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. G. 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. *COMAR 14.35.07.15* A. 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. B. 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. C. 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. D. 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. E. 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. F. 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. G. 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 §F of 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. H. 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. *COMAR 14.35.07.16* A. 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. B. 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. C. 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. D. 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. E. 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. F. 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. G. 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 violation of a material provision of the contract in relation to the enrollee or the enrollee’s dependent. #### Regulation .17 Special Enrollment Period — Exceptional Circumstances Through the Individual Exchange. *COMAR 14.35.07.17* A. 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. B. 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. C. 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. D. 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. E. 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. F. 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. *COMAR 14.35.07.18* A. 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. B. 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. C. 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. D. 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. *COMAR 14.35.07.19* A. 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. B. 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. C. 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. D. 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. E. 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. F. 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. G. 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). H. 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. I. 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. J. 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. K. 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. L. 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. M. 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. N. 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. O. 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 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. P. 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. *COMAR 14.35.07.20* A. As set forth in 45 CFR §155.625(b), the Individual Exchange has delegated administration of all exemption determinations for Maryland residents to HHS. B. 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. C. The Individual Exchange may administer exemption determinations for Maryland residents. D. 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. *COMAR 14.35.07.21* 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. *COMAR 14.35.07.22* A. 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. B. 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. C. 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. D. 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. E. 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. F. 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. G. 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. *COMAR 14.35.07.23* A. The Exchange shall redetermine the eligibility of a qualified individual on an annual basis as specified in 45 CFR §155.335. B. 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). C. 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. D. 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. E. 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. F. 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.