Chapter 13. State Employees' Health Benefits

In accordance with State Personnel and Pensions Article, Annotated Code of Maryland; or

For service as a judge.

Is one of the following:

Subject further to §B(6-1) of this regulation, is either:

Under the age of 25, through the end of the month in which the child turned 25; or

At the time of reaching the age of 25, incapable of self-support because of a mental or physical incapacity that started before the child reached age 25 and is chiefly dependent for support on the employee or the retired employee.

A county;

Baltimore City; or

A municipal corporation as defined in Article 23A, §9, Annotated Code of Maryland.

Central Payroll Bureau;

Maryland Transit Administration; or

The institutions of the University System of Maryland, including graduate assistants, and the Far East and European Divisions of the University of Maryland;

In the case of more than one dependent child receiving the allowances or distributions noted above, each dependent child who receives the allowance or distribution is eligible to enroll independently; and

Notwithstanding any other provision in this regulation, a surviving spouse or surviving child must meet the requirements to be a dependent eligible for coverage as provided in §A(9) of this regulation;

Receive a retirement allowance pursuant to State Personnel and Pensions Article, Division II, Annotated Code of Maryland, and who have:

Receive a periodic distribution of benefits from the Maryland Optional Retirement Program under State Personnel and Pensions Article, Title 30, Annotated Code of Maryland, and who have:

Receive a retirement allowance pursuant to State Personnel and Pensions Article, Division II, Annotated Code of Maryland, and who have:

Receive a periodic distribution of benefits from the Maryland Optional Retirement Program under State Personnel and Pensions Article, Title 30, Annotated Code of Maryland, and who have:

A spouse of an employee or retired employee; or

A dependent child or another dependent child relative of an employee or retired employee, as identified in this chapter.

An eligible employee or retired employee shall apply for coverage for himself and eligible dependents within 60 days of the employment or retirement date by submitting to the appointing authority an application and payroll deduction authorization form for the coverage desired or shall wait for the annual open enrollment period unless otherwise indicated in §C of this regulation. The Salary Reduction Agreement may be combined with the electronic enrollment form completed by the employee (or the employee’s representative) using the State’s selected human capital management system. Coverage shall be effective in accordance with Eligibility Provisions. Coverage is purchased pretax on a prospective basis only in accordance with the State cafeteria plan adopted by the Department of Budget and Management in accordance with federal tax law. Employees will receive invoices for all outstanding coverage fees which are not satisfied through a payroll deduction; these amounts will not be on a pretax basis.

Coverage for later acquired or newly eligible dependents of a covered employee or retired employee is obtained by submitting, in the case of an active employee, an electronic enrollment form completed by the employee (or the employee’s representative) using the State’s selected human capital management system or, in the case of a retired employee, an electronic enrollment form completed by the employee (or the employee’s representative) using the State’s selected human capital management system or an application to the Department of Budget and Management within 60 days of the change in status. Coverage shall be effective in accordance with Eligibility Provisions. Coverage is purchased pretax on a prospective basis only in accordance with the State cafeteria plan adopted by the Department of Budget and Management in accordance with federal tax law. Employees will receive invoices for all outstanding coverage fees which are not satisfied through a payroll deduction; these amounts will not be on a pretax basis.

A newborn child may be covered from birth when maternity benefits are provided. However, the employee shall make application within 60 days from the date of the child’s birth to convert to an appropriate membership to provide coverage for the newborn child. Coverage for the newborn shall be effective on the date of birth provided the employee submits an electronic enrollment form completed by the employee (or the employee’s representative) using the State’s selected human capital management system within 60 days of the date of birth. Coverage is purchased pre-tax on a prospective basis only in accordance with the State cafeteria plan adopted by the Department of Budget and Management in accordance with federal tax law.

An eligible contractual employee working more than 30 hours per week, or an average of 130 hours per month, as determined after any necessary measurement period, shall apply for coverage for himself and eligible dependents within 60 days of eligibility by submitting an electronic enrollment form completed by the employee (or the employee’s representative) using the State’s selected human capital management system for the coverage desired, or shall wait for the annual open enrollment period unless otherwise indicated in §C of this regulation. The eligible contractual employee working more than 30 hours per week, or an average of 130 hours per month, shall be provided a State subsidy equal to 75 percent of the premium for elected medical and prescription drug coverage. The employee shall pay 25 percent of the total cost of the premium in accordance with the direct billing procedures of the Department of Budget and Management. For all other coverage elected, the employee shall pay the total cost of the premium in accordance with the direct billing procedures of the Department of Budget and Management and may not receive a State subsidy. Coverage shall be effective in accordance with Eligibility Provisions.

Coverage for later acquired or newly eligible dependents of a covered contractual employee is obtained by submitting an electronic enrollment form completed by the employee (or the employee’s representative) using the State’s selected human capital management system within 60 days of the change in status. Coverage for that dependent shall be effective in accordance with Eligibility Provisions

A newborn child may be covered from birth when maternity benefits are provided. However, the employee shall make application within 60 days from the date of the child’s birth to convert to an appropriate membership to provide coverage for the newborn child. Coverage for the newborn shall be effective as of the child’s date of birth provided the employee submits an electronic enrollment form completed by the employee (or the employee’s representative) using the State’s selected human capital management system within 60 days of the date of birth.

An eligible permanent employee working less than 50 percent of the workweek or contractual employee working less than 30 hours per week or 130 hours per month may apply for coverage for the employee and eligible dependents within 60 days of employment by submitting an electronic enrollment form completed by the employee (or the employee’s representative) using the State’s selected human capital management system for the coverage desired, or shall wait for the annual open enrollment period. Such employees shall pay the total cost of the premium in accordance with the direct billing procedures of the Department of Budget and Management and may not receive a State subsidy. Coverage shall be effective in accordance with Eligibility Provisions.

An eligible permanent employee working less than 50 percent of the workweek or contractual employee working less than 30 hours per week or 130 hours per month may obtain coverage for later acquired or newly eligible dependents by submitting an electronic enrollment form completed by the employee (or the employee’s representative) using the State’s selected human capital management system for the coverage desired within 60 days of the qualifying event, or shall wait for the annual open enrollment period. Coverage for that dependent shall be in accordance with Eligibility Provisions.

A newborn child may be covered from birth when maternity benefits are provided. However, the employee shall make application within 60 days from the date of the child’s birth to convert to an appropriate membership to provide coverage for the newborn child. Coverage for the newborn shall be effective as of the date of birth provided the employee submits an electronic enrollment form completed by the employee (or the employee’s representative) using the State’s selected human capital management system.

Retirees and their designated beneficiaries who qualify for the maximum State subsidy to pay 25 percent of the premium for the prescription drug benefit; and

Retirees and their designated beneficiaries who qualify for a partial State subsidy to pay 25 percent of the premium for the prescription drug benefit plus the proportional additional amount required under State Personnel and Pensions Article, §2-508(b)(4)(ii) and (c)(4)(ii), Annotated Code of Maryland; and

$1,500 per plan year for the retiree only coverage; and

$2,000 per plan year for the retiree plus dependent(s) coverage.

Consistent with the diagnosis and treatment of the member's condition;

In accordance with standards of good medical practice;

Required for reasons other than the convenience of the member, practitioner, or other provider; and

The most appropriate supply or level of service which can safely be provided for the member.

The fee usually charged by a health care provider to all patients for a particular service or supply;

The fee customarily charged by health care providers for the same service or supply in the same general area; or

The actual fee charged by a health care provider to a patient for a particular service or supply.

Eligible employees 65 years old or older, who are eligible for health benefits in accordance with Regulation .03 of this chapter;

Eligible spouses 65 years old or older, of employees who are any age, and who are eligible for health benefits in accordance with Regulation .03 of this chapter.

An employee 65 years old or older, or an employee's spouse 65 years old or older, shall designate coverage under the State employees' health insurance program or Medicare. Those employees and spouses who elect coverage under the State employees' health insurance program shall receive coverage under the applicable membership as would be applicable to all other State employees and their dependents without Medicare.

In accordance with applicable federal law, those employees and spouses who elect coverage under Medicare are ineligible for benefits under the Medicare Supplemental Program or other health insurance coverage available to all other State employees.

Upon retirement from State service by the employee 65 years old or older, the retired employee and spouse are eligible for benefits under the Medicare Supplemental Program as applicable to all other State retired employees.

“Claim” means a demand for payment or benefit under a plan, policy or contract by a covered individual under the Program, an insured, a third party, a provider, or a representative of any of them.

“Claim” includes a demand made to the State, the Department, a contractor, or any representative or agent of the State, the Department, or a contractor in connection with the Program.

“Contractor” means a person, business, or organization under contract with the State or the Department to provide goods or services under the Program.

“Contractor” includes a third-party administrator, insurer, carrier, or other agent, including a subcontractor of a third-party administrator, insurer, or carrier, that administers or processes claims or approves benefits and services in the Program.

Concealing, falsifying, or omitting of a material fact;

Making of a materially false or fraudulent statement; or

Use of a document that contains a statement of material fact that the user knows to be false or fraudulent.

“Fraud” means the intentional perversion of the truth taken with the intent to gain something of value or to induce another to part with something of value.

“Fraud” includes but is not limited to:

“Health care service” means health or medical care procedures, goods, or services that:

“Health care service” includes any procedure, goods, or service that is a required, available, or covered benefit in any health, medical, prescription, or dental plan option provided through the Program.

“Provider” means an individual, company, facility, organization, or other entity that supplies services or benefits that are covered under the Program.

“Provider” includes, but is not limited to, a doctor, pharmacist, hospital, or other medical professional rendering services within their expertise.

By fraud, deceit, false representation, or concealment;

By counterfeiting or alteration of a prescription;

By concealment of a material fact;

By using a false name or a false address; or

For purposes other than the legitimate treatment of the covered individual's medical condition;

Seeking or receiving information from:

Review or use of past claims history or medical information relevant to the covered individual; or

Other steps that the Director determines are necessary to conclude whether there is cause for termination of coverage.

Prior to a termination of coverage described in §B of this regulation, the covered individual shall be provided with written notice of the termination and the cause for termination.

The notice may include a demand for repayment of any monies paid by the State through the Program.

The notice shall:

An employee covered by State Personnel and Pensions Article, Title 12, Annotated Code of Maryland, may file a grievance under that title related to any action taken pursuant to this regulation.

Otherwise, an individual may request a hearing, to be held in accordance with COMAR 17.02.03, to challenge a termination of coverage taken pursuant to this regulation. The request shall be made in writing to the Secretary within 20 days of the date the individual received the notice of coverage termination. Such hearings, and the record, shall be closed to the extent that failure to close the hearing and protect the record will disclose protected health information, as such term is defined in 45 CFR §160.103.

“Conscientious objection” means a statement that the individual holds sincere beliefs or practices of a religious, moral, or cultural nature that prohibit the individual from participating in one or more of the healthy activities requirements or in the Wellness Program as a whole.

“Department” means the Department of Budget and Management.

“Director” means the individual appointed to manage the Employee Benefits Division or unit of the Department with primary responsibility of managing the Program.

“Health care provider” has the same meaning as “health professional” in State Personnel and Pensions Article, §9-504(b), Annotated Code of Maryland.

“Healthy activities requirements” means those activities that must be completed in order for an individual to obtain the full rewards available under the Wellness Program.

“Reasonable alternative” means an activity that may be substituted for a healthy activities requirement and that may provide an individual with an alternate method of qualifying for the opportunity to earn the full rewards available under the Wellness Program.

“Reward” means:

“Waiver” means a determination by the Director’s designee to exempt an individual from participating in the Wellness Program.

“Wellness Program” means the program within the State Employee and Retiree Health and Welfare Benefits Program and described in this regulation and in the Guide to Your Health Benefits provided by the Department for the current plan year.

If the retiree is Medicare-eligible, but the spouse is not, the spouse is exempt from the wellness requirements; and

The Wellness Program does not apply to retirees and retirees’ spouses for whom Medicare is primary.

A request for a waiver shall be submitted in writing to the Employee Benefits Division and shall be signed by the individual who is seeking the waiver.

A request for a waiver shall include a statement that articulates the sincerely held belief or practice of a religious, moral, or cultural nature that prohibits the requestor from participating in the healthy activities requirements, and an explanation of how the beliefs or practices prohibit such participation.

The Director may designate two or more employees as members of a Waiver Committee, consistent with the specifications of this regulation, to review and evaluate requests. At least one employee member shall be from the Employee Benefits Division of the Department’s Office of Personnel Services and Benefits.

For each request, the Waiver Committee shall make a recommendation to the Director’s designee to grant or deny the request, or to request additional information from the requestor.

The Director’s designee has discretion to accept or reject the recommendation and may request additional information from the Waiver Committee or from the requestor.

The Director’s designee shall issue a written determination approving or denying the request for a waiver as soon as practicable.

Approval or denial of the request for a waiver is discretionary, subject only to abuse of that discretion, and may be based on any legally permissible reason.

A determination approving a request for a waiver shall state the healthy activities to which it applies.

A determination denying a request for a waiver shall include instructions for requesting reconsideration.

Any individual for whom, for that period, it is unreasonably difficult due to a medical condition to satisfy the healthy activities requirements; and

Any individual for whom, for that period, it is medically inadvisable to attempt to satisfy the healthy activities requirements.

A request for a reasonable alternative shall be submitted in writing to the Employee Benefits Division and shall be signed by the individual who is seeking the reasonable alternative, the individual’s Power of Attorney, or another individual otherwise authorized to act on behalf of the individual.

A request for a waiver shall include a statement that articulates the basis for the request.

A request for a reasonable alternative to the healthy activities requirements may include documentation that supports the stated basis for the request. Where an individual provides credible support that it is unreasonably difficult due to a medical condition to satisfy the healthy activities requirements or that it is medically inadvisable to attempt to satisfy the healthy activities requirements, a reasonable alternative shall be permitted, or the individual shall be exempted from the healthy activities requirement.

A reasonable alternative determined by the individual’s health care provider shall be permitted upon the individual’s request.

The Director’s designee may request verification, in the form of a signed and dated statement from the individual’s health care provider, that a health factor makes it unreasonably difficult for the individual to satisfy, or medically inadvisable for the individual to attempt to satisfy, the healthy activities requirements in an activity-only wellness program.

If the individual’s health care provider states that a healthy activities requirement is not medically appropriate for that individual, the Director’s designee shall permit a reasonable alternative that accommodates the recommendations of the individual’s health care provider with regard to medical appropriateness, which may include an exemption from the healthy activities requirements.

A health care provider’s recommendation for a reasonable alternative or statement in support of a request for a reasonable alternative, which may include exemption, shall be on official letterhead, signed and dated, in order to be considered.

The Director’s designee shall issue a written determination approving or denying the request for a reasonable alternative as soon as practicable.

Approval of a request for a reasonable alternative is discretionary, subject only to abuse of that discretion, and denial may be based on any legally permissible reason.

A determination authorizing a reasonable alternative shall describe the reasonable alternative and, if appropriate, state the healthy activities to which it applies.

A determination denying a request for a reasonable alternative shall include instructions for requesting reconsideration.