In this chapter, the following terms have the meanings indicated. Terms Defined. “Beneficiary” means an employee, judge, teacher, member of the optional retirement system, or correctional officer who receives a retirement allowance in accordance with State Personnel and Pensions Article, Annotated Code of Maryland, excluding faculty and staff of community colleges and teachers and staff employed by local boards of education. “Creditable service” means service credited toward a retirement allowance: In accordance with State Personnel and Pensions Article, Annotated Code of Maryland; or For service as a judge. “Dependent child” means an individual who meets the following requirements: Is one of the following: A biological child of the employee or retired employee; An adopted child of or a child placed for adoption by an employee or retired employee; A stepchild of the employee or retired employee; A grandchild of an employee or retired employee who permanently resides with the employee or retired employee, and meets the requirements of 26 U.S.C. §§105, 106, and 125, and federal regulations implementing those statutory provisions for tax preferred health benefit coverage; A child under a testamentary or court appointed guardianship, other than a temporary guardianship of less than 12 months duration, of the employee or retired employee who permanently resides with the employee or retired employee, and meets the requirements of 26 U.S.C. §§105, 106, and 125, and federal regulations implementing those statutory provisions for tax preferred health benefit coverage; or A child who is related to the employee or retired employee by blood or marriage, is solely supported by and permanently resides with the employee or retired employee, and meets the requirements of 26 U.S.C. §§105, 106, and 125, and federal regulations implementing those statutory provisions for tax preferred health benefit coverage; and Subject further to §B(6-1) of this regulation, is either: Under the age of 26, through the end of the month in which the child turned 26; or At the time of reaching the age of 26, incapable of self-support because of a mental or physical incapacity that started before the child reached age 26 and is chiefly dependent for support on the employee or the retired employee. “Designated beneficiary” means a surviving spouse or dependent child of an employee or retired employee receiving a retirement allowance. “Health Benefits Administrator” means the administrator of the State employees' health benefits program of the Department of Budget and Management. “Normal retirement age” means the age at which a vested retirement allowance shall begin. “Other dependent child relative” is a subset of “dependent child” and means a dependent child who is not a biological child, adopted child, or stepchild of an employee or retired employee, nor a child placed for adoption by an employee or retired employee, and 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. “Political subdivision” means any of the following: A county; Baltimore City; or A municipal corporation as defined in Article 23A, §9, Annotated Code of Maryland. “Program” means the State Employee and Retiree Health and Welfare Benefits Program. “Secretary” means the Secretary of Budget and Management. “Spouse” means an individual who is lawfully joined in marriage to an employee or retired employee. “State service” means service with the State as an employee, judge, teacher, member of the optional retirement system, or correctional officer as defined in State Personnel and Pensions Article, Annotated Code of Maryland, excluding service as faculty and staff of community colleges and service as teachers and staff employed by local boards of education. Eligible Persons. The following persons are eligible for Program coverage, with the exception of those persons listed in §B of this regulation: Employees whose coverage is required by law, full-time employees, and part-time employees as defined by State Personnel and Pensions Article, §7-701, Annotated Code of Maryland, who are regularly paid salary or wages through an official State payroll center, including but not limited to: 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; Elected officials; Registers of wills and employees of the offices of registers of wills; Clerks of court and employees of the offices of clerks of court; Board or commission members who are regularly paid salary or wages and who work at least 50 percent of a normal workweek; Designated beneficiaries of deceased persons listed in §A(1)—(5), (7), and (8) of this regulation in accordance with State Personnel and Pensions Article, §§2-507, 2-508 and 2-509, Annotated Code of Maryland, with the following limitations: 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; Retired employees who began State service on or before June 30, 2011, or who began State service on or after July 1, 2011 and are retirees of the Judges’ Retirement System, and who qualify in accordance with §§A(7)(a) and (b) of this regulation. Neither service as a faculty member, teacher, or staff member for a community college or a local board of education prior or subsequent to State service, nor membership in the Teachers’ Pension or Retirement Systems, shall in itself disqualify a former State employee who is otherwise eligible under §A(7)of this regulation. The only retired employees eligible for benefits under §A(7) of this regulation are those who: Receive a retirement allowance pursuant to State Personnel and Pensions Article, Division II, Annotated Code of Maryland, and who have: Retired directly from State service with a State retirement allowance on or after July 1, 1984, provided that the employee had at least 5 years of creditable service; Terminated State service with 16 years or more of creditable service; Terminated State service before July 1, 1984; or Terminated State service with 10 years of creditable service and within 5 years of normal retirement age; or 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: Ended service with a State institution of higher education with at least 10 years of service and were at least age 57; Ended service with a State institution of higher education with at least 16 years of service; or Retired directly from and had at least 5 years of service with a State institution of higher education on or after July 1, 1984; Retired employees who began State service on or after July 1, 2011, and who qualify in accordance with §A(8)(a) and (b) of this regulation. Neither service as a faculty member, teacher, or staff member for a community college or a local board of education prior or subsequent to State service, nor membership in the Teachers’ Pension or Retirement Systems, shall in itself disqualify a former State employee who is otherwise eligible under §A(8) of this regulation. The only retired employees eligible for benefits under §A(8) of this regulation are those who: Receive a retirement allowance pursuant to State Personnel and Pensions Article, Division II, Annotated Code of Maryland, and who have: Retired directly from State service with a State retirement allowance provided that the employee had at least 10 years of creditable service; Terminated State service with 25 years or more of creditable service; or Terminated State service with 10 years of creditable service and within 5 years of normal retirement age; or 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: Ended service with a State institution of higher education with at least 10 years of service and were at least age 57; Ended service with a State institution of higher education with at least 25 years of service; or Retired directly from and had at least 10 years of service with a State institution of higher education on or after July 1, 2011; Dependents of eligible persons listed in §A(1)—(5), (7), (8), (10), and (11) of this regulation who are one of the following: 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. Employees working less than 50 percent of a normal workweek and their designated beneficiaries, in accordance with Regulation .04B(3) of this chapter; and Contractual employees regularly working at least 30 hours per week, or an average of 130 hours per month, in accordance with 26 USC § 4980(H) and Regulation .04B(2) of this chapter. Ineligible Dependents. Dependents of persons who are ineligible are likewise ineligible for coverage. When both spouses are covered as an employee or retired employee, neither is eligible to be enrolled both as a dependent under the spouse's coverage and as an employee or retiree for the same benefits plan. Dependent children of these individuals may be enrolled under either parent's coverage, but not both for the same benefits plan. An employee or retiree may provide coverage for his or her spouse who is also an employee provided that the spouse is not enrolled for coverage under the same benefits plan as an employee or retiree. Dependent children of employees who are also employees are not eligible to be enrolled as dependents under their parent's coverage if they have enrolled as individuals. Subsidy. Except as provided in Regulation .04B of this chapter for contractual and part-time employees, the State subsidy as provided in the State budget for active employees is available to those individuals identified in §A(1)—(5) of this regulation and their dependents as described in §A(9) of this regulation. The State subsidy available for individuals described in §A(6) of this regulation shall be determined as provided in Regulation .05 of this chapter. The State subsidy available for individuals described in §A(7) and (8) of this regulation and their dependents as described in §A(9) of this regulation shall be determined as provided in Regulation .05 of this chapter, provided that the dependents of those retired employees described in §A(7)(b) and (8)(b) of this regulation are not entitled to any State subsidy unless the retired employee has a total of 25 or more years of service with the State in a permanent, non-contractual position in the Executive, Judicial, or Legislative branch of State government. Prorated credit for service is provided for less than full-time service in such positions. Contractual employees regularly working more than 30 hours per week, or more than an average of 130 hours per month, shall be provided a State subsidy of 75 percent of the premium cost for medical and prescription drug coverage. A measurement period may be necessary to establish the contractual employee’s eligibility for the State subsidy. Employees working less than 50 percent of the workweek and contractual employees working less than 30 hours per week or 130 hours per month, as determined by either the employment contract or the Affordable Care Act measurement period analysis, shall not be provided a State subsidy. The employees of the following entities are eligible to participate in the Program upon the application of the entity, provided that, at the discretion of the Secretary, such participation does not impede, undermine, or conflict with the Program’s federal compliance obligations or governmental and cafeteria plan status: A county or municipal corporation with the approval of the governing body of the county or municipal corporation; and Agencies, commissions, or organizations permitted to participate in the State's health insurance program by law. Each entity identified in §A of this regulation shall permit the spouses and dependent children of its employees to be eligible for coverage but may elect whether and to what extent to provide a subsidy for the participation in the Program of its employees and their dependents. Eligibility. Generally, each employee is eligible for coverage on the first scheduled working day. Each retired employee is eligible for coverage on the first day of retirement or the first day of election in accordance with §B(1)(a) of this regulation. Dependents of covered employees or retired employees are eligible on the date the employee or retired employee becomes eligible. Later acquired dependents become eligible on the date they become dependents of a covered employee or retired employee. Eligibility for the State subsidy may come at a date separate from and subsequent to eligibility for coverage in general. Coverage. Eligible Employees Listed in Regulation .03A(1)—(8) of 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. Contractual Employees Working More than 30 Hours per Week or 130 Hours per Month. 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. Permanent Employees Working Less than 50 Percent of the Workweek and Contractual Employees Working Less than 30 Hours per Week. 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. Permissible Changes in Coverage. Except as provided in §C(2) of this regulation, changes in coverage outside of Open Enrollment may be made only if and when those changes are permissible in a cafeteria plan governed by 26 U.S.C. §125 and 26 CFR §§1.125-1—1.125-7. Changes in coverage for eligible dependents who are covered on a post-tax basis are permissible if and when such changes are consistent with the requirements of §C(1) of this regulation. In determining whether the requested change is consistent, the eligible dependent shall be treated as if the coverage is provided on a pre-tax basis. A retired employee who began State service on or before June 30, 2011, and the designated beneficiaries of a retired employee who began State service on or before June 30, 2011, and a retired employee of the Judges’ Retirement System who began State service on or after July 1, 2011, and the designated beneficiaries of a retired employee of the Judges’ Retirement System who began State service on or after July 1, 2011, are eligible to receive the subsidy provided by the State for the cost of the health insurance benefits program on the following basis: If an employee retired directly from State service before July 1, 1984, the retired employee and the designated beneficiaries of the retired employee shall receive the same subsidy that is provided to a State employee; If an employee retired from State service on or after July 1, 1984 and had at least 5 years of creditable service, the retired employee and the designated beneficiaries of the retired employee shall receive 5/16 of the subsidy provided to a State employee; If an employee retired from State service on or after July 1, 1984 and had more than 5 but less than 16 years of creditable service, the retired employee and the designated beneficiaries of the retired employee shall receive 1/16 of the subsidy for each year of creditable service that is more than 5 but less than 16 years; If an employee retired from State service on or after July 1, 1984 and had 16 years or more of creditable service, the retired employee and the designated beneficiaries of the retired employee shall receive the same subsidy that is provided to a State employee; If a retired employee is in receipt of a State disability retirement allowance, the retired employee and the designated beneficiaries of the retired employee shall receive the same subsidy that is provided to a State employee; Except as provided in §A(7) of this regulation, a person in receipt of a special death benefit under State Personnel and Pensions Article, §29-204, Annotated Code of Maryland, shall receive the same subsidy that is provided to a State employee; and If a retired State employee retires with a periodic benefit under the Optional Retirement System of State Personnel and Pensions Article, Title 30, Annotated Code of Maryland, the retiree and the dependents of the retiree shall receive the subsidy provided pursuant to State Personnel and Pensions Article, §2-509(a), Annotated Code of Maryland. A retired employee who began State service on or after July 1, 2011 and the designated beneficiaries of a retired employee who began State service on or after July 1, 2011 are eligible to receive the subsidy provided by the State for the cost of the health insurance benefits program on the following basis: If an employee retired from State service and had at least 10 years of creditable service, the retired employee and the designated beneficiaries of the retired employee shall receive 10/25 of the subsidy provided to a State employee; If an employee retired from State service and had more than 10 but less than 25 years of creditable service, the retired employee and the designated beneficiaries of the retired employee shall receive 1/25 of the subsidy for each year of creditable service that is more than 10 but less than 25 years; If an employee retired from State service and had 25 or more years of creditable service, the retired employee and the designated beneficiaries of the retired employee shall receive the same subsidy that is provided to a State employee; If a retired employee is in receipt of a State disability retirement allowance, the retired employee and the designated beneficiaries of the retired employee shall receive the same subsidy that is provided to a State employee; Except as provided in §B(6) of this regulation, a person in receipt of a special death benefit under State Personnel and Pensions Article, §29-204, Annotated Code of Maryland, shall receive the same subsidy that is provided to a State employee; and If a retired State employee retires with a periodic benefit under the Optional Retirement System of State Personnel and Pensions Article, Title 30, Annotated Code of Maryland, the retiree and the dependents of the retiree shall receive the subsidy provided pursuant to State Personnel and Pensions Article, §2-509(b), Annotated Code of Maryland. The health insurance benefit for eligible retirees and their designated beneficiaries includes a prescription drug benefit that: Has the same copayments, coinsurance, and deductible that apply to the prescription drug benefit for active State employees; Requires: 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 Requires retirees and designated beneficiaries to pay out-of-pocket limits up to: $1,500 per plan year for the retiree only coverage; and $2,000 per plan year for the retiree plus dependent(s) coverage. Beginning on July 1, 2020, Medicare-eligible retirees will cease to be eligible for the prescription drug benefit option provided under the State Employee and Retiree Health and Welfare Benefits Program. A retired employee and the designated beneficiaries of the retired employee shall pay the remainder of the cost of the health insurance benefits premium that is not provided for under §§A—D of this regulation. Under certain circumstances, participants in the State employees' health insurance benefits program may arrange for direct billing and payment of health insurance premiums in accordance with Department of Budget and Management procedures. Definitions. In this regulation, the following terms have the meanings indicated: “Medically necessary” means those services and supplies provided by a hospital, practitioner, or other provider of health care services to identify or treat an illness or injury which has been diagnosed or is reasonably suspected, and which are: 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. “Reasonable cost” means the lowest of the following costs: 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. The Medicare Supplemental Program shall provide benefits as follows: Benefits or payments under the Medicare Supplemental Program shall be provided in accordance with the reasonable cost of a medically necessary service or supply. Benefits or payments under the Medicare Supplemental Program may not duplicate any benefits payable by Medicare. With respect to members eligible for Medicare, whether those members are enrolled under Part A (Hospital Insurance) or Part B (Medical Insurance) of Title XVIII of the Social Security Amendments of 1965 (Title I of Public Law 89—97), the benefits provided under the Medicare Supplemental Program shall be reduced by the amount of benefit or payment that would have been furnished the member under Title XVIII, if that member had been enrolled. Benefits furnished under Title XVIII, or that would have been furnished under Title XVIII, shall be charged against the maximum benefits provided for under the Medicare Supplemental Program. Eligible Persons. Retired employees and their spouses and dependents who are eligible for Medicare benefits and who are eligible for retired employee health benefits in accordance with Regulation .03A(10) of this chapter are eligible for benefits provided under the Medicare Supplemental Program. Effective Dates. Eligibility. At the start of the calendar month in which age 65 is reached or Medicare eligibility is otherwise established, a retired employee and eligible spouse and dependents are eligible for benefits under the Medicare Supplemental Program. Coverage. At the start of the calendar month in which age 65 is reached or Medicare eligibility is otherwise established, the retired employee's membership shall be automatically converted to an appropriate membership level under the Medicare Supplemental Program. Election of Coverage of Employees 65 Years Old or Older, and Employees' Spouses 65 Years Old or Older. Eligibility. Not later than the calendar month in which age 65 is reached, the following persons shall designate their election of coverage of the State employees' health insurance program or Medicare as their primary health insurance carrier: 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. Coverage. 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. In this regulation, the following terms have the meanings indicated: Claim. “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. “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. “Coverage” includes all coverage or benefits plans or options in which an individual is enrolled through the Program. “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 for administering the Program. "False representation" means the knowing and willful: 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. “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: The willful making of a false statement or a false representation; or The impersonation of another. Health Care Service. “Health care service” means health or medical care procedures, goods, or services that: Provide testing, diagnosis, or treatment of human disease or dysfunction; or Dispense drugs, medical devices, medical appliances, or medical goods for the treatment of human disease or dysfunction. “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. “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. “Representation” means a statement and includes an acknowledgment, certification, claim, ratification, or report. Scope of Termination of Coverage. The Secretary may terminate coverage in the Program of an individual otherwise eligible for coverage under Regulation .03 or .03-1 of this chapter using the procedures outlined in this regulation. Such termination may be: Permanent or for a period of time; and Of all Program coverage or of coverage in one or more benefits plans or benefits options. Causes for Termination of Benefits. Program coverage may be terminated if a covered individual: Knowingly makes, uses, or causes to be made or used a false record, representation, or statement to get or attempt to get a claim paid or approved under the Program; Conspires to defraud the State or the Department by getting or attempting to get a false or fraudulent claim approved or paid under the Program; Knowingly gets or attempts to get a false or fraudulent claim paid or approved under the Program for an amount higher than the amount billed by the provider, paid to the provider, charged by the provider, or owed to the provider; Knowingly makes, uses, or causes to be made or used a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or other property under the Program; Knowingly makes a false or fraudulent claim for health care services under the Program; Knowingly obtains, attempts to obtain, or aids another individual in obtaining or attempting to obtain a drug product, medication, medical care, or other health care service, if the payment of all or part of the payment is or may be made under the Program: 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; Knowingly enrolls, attempts to enroll, or aids another individual in enrolling or attempting to enroll in coverage under the Program if eligibility for coverage is not authorized under law, including but not limited to false representation concerning eligibility for Program coverage; Knowingly presents or causes to be presented to an officer, employee, or agent of the State or the Department, contractor, provider, or other person receiving State or Departmental funds a false or fraudulent claim for payment or benefit approval under the Program; or Commits or attempts to commit fraud in connection with the Program. Process for Termination of Coverage. The Director shall investigate allegations, instances, or occurrences that may justify termination in the Program. To the extent it is not prohibited by applicable law, an investigation may include: Seeking or receiving information from: A provider; A law enforcement agency, official, officer, or employee; A contractor in the Program; or The covered individual or the person who has elected coverage for the covered individual; 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 concluding that there is cause for termination of coverage, the Director shall notify the covered individual of the investigation and provide the individual with the opportunity, lasting at least 14 days, to submit information relevant to the investigation. Upon concluding that there is cause for termination of coverage, the Director shall make a recommendation to the Secretary for a decision. Notice of 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: Be issued at least 15 business days prior to the date termination will take effect; In the case of a dependent, be provided as well to the individual, identified in Regulation .03A or .03-1 of this chapter, who elected coverage of the dependent; Identify the cause for termination of coverage; Identify the date on which coverage will terminate; Identify the scope of the termination; Inform the covered individual whether continuation coverage is available; and Be sent certified and regular mail to the last address on record with the Department for the covered individual. Appeal of Termination of Coverage. 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. Departmental Action. In the event of the termination of Program coverage of an active employee, the Secretary shall notify the benefits coordinator of the employing agency of the termination of coverage; however, the notice may not include any description or explanation of the basis of the termination unless that disclosure is authorized pursuant to relevant confidentiality or protection of privacy laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all pertinent regulations (for example, 45 CFR Parts 160 and 164) promulgated pursuant to HIPAA. The Secretary or a designee shall refer the results of any investigation that an employee has made a false representation concerning eligibility for Program coverage of any individual or committed any activity identified in §C(7) of this regulation to the appointing authority, employing agency or employing satellite organization. The notice of termination may only be made if the false representation is or is contained in enrollment information available to the appointing authority, employing agency, or employing satellite organization in a personnel file or other employment materials. Such situations include when an employee presents to the appointing authority, employing agency, or employing satellite organization for submission to the Department a false, counterfeit, or altered birth certificate, marriage certificate, or affidavit that supports the enrollment of a dependent. The Department may seek repayment or restitution from the individual whose coverage has been terminated for cause as identified in §C of this regulation for the value of the payments made or benefits provided under the Program under such circumstances. In the case of the termination of coverage of an individual, identified in Regulation .03A(1)—(6), (8), (10), and (11) or .03-1 of this chapter, who is eligible to elect coverage for a dependent, the Program coverage of all covered dependents will also be terminated. The Department shall take steps to discontinue any payroll deduction or automatic contribution from a retirement allowance for coverage that has been terminated. Definitions. In this regulation, the following terms have the meanings indicated. Terms Defined. “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: Obtaining an incentive, such as a waiver of all or part of a cost-sharing mechanism, which may include deductibles, copayments, or coinsurance; and Avoidance of a penalty, such as the absence of a surcharge or other financial or nonfinancial disincentive. “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. General Provisions and Scope of the Wellness Program. There is a Wellness Program that is administered by the Department. The Wellness Program has been designed to comply with all applicable State and federal laws, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Patient Protection and Affordable Care Act (ACA), and the Genetic Information Non-Discrimination Act (GINA) of 2008. The Wellness Program applies to employees, non-Medicare-eligible retirees and non-Medicare-eligible enrolled spouses, subject to the following: 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. During years 2015 and 2016, the Wellness Program does not apply to enrolled children regardless of age. The Wellness Program may be expanded in future years to include children, as may be described in the Guide to Your Health Benefits provided by the Department for the applicable year. Each individual to whom the Wellness Program applies shall have the opportunity to qualify for the rewards at least once per year. Waivers. The Wellness Program includes the opportunity to request a waiver from participating in the Wellness Program as a whole or from participating in one or more of the healthy activities requirements on the basis of conscientious objection. An individual who obtains a waiver from participating in the Wellness Program may not qualify for incentive-based rewards or be subject to a surcharge or other financial or nonfinancial disincentive. Request for a Waiver. 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. Committee to Review Requests for Waivers. 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. Determination by the Director’s Designee. 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. Reasonable Alternatives. The Wellness Program shall allow a reasonable alternative to or exemption from the healthy activities requirements for: 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. Request for a Reasonable Alternative. 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. Determination by the Director’s Designee. 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. Reconsideration. An individual may request reconsideration of the determination denying a request for waiver or reasonable alternative. A request for reconsideration must be submitted to the Director within 10 days of receipt of the determination. A request for reconsideration shall state the reasons the individual believes the determination should be reconsidered and may be accompanied by supporting documentation. The Director or designee shall issue a response to the request for reconsideration in writing within 30 calendar days of receipt of the request. The designee may not be the same employee who issued the underlying written determination. Confidentiality of Medical Documentation. All medical documentation submitted with a request for waiver or reasonable alternative shall be treated as confidential and shall be disclosed only as permitted by applicable law and only to those individuals who need to know its contents as part of the review, evaluation, determination, and reconsideration process, in accordance with the ACA, HIPAA, and GINA. State Personnel and Pensions Article, Title 2, Subtitle 5, Title 4, Subtitle 1, and Title 8, Subtitle 1, Annotated Code of Maryland Effective date: December 30, 1985 (12:26 Md. R. 2542) Chapter revised effective February 9, 1987 (14:3 Md. R. 271) For a history of State Personnel Regulations before February 12, 1997, see the prior version of COMAR Title 06 or contact the Maryland State Archives for assistance. Regulation .01 repealed and new Regulation .01 adopted as an emergency provision effective July 1, 2008 (35:15 Md. R. 1346); adopted permanently effective August 25, 2008 (35:17 Md. R. 1489) Regulation .01B amended effective July 1, 2009 (36:10 Md. R. 717); September 20, 2010 (37:19 Md. R. 1284); October 3, 2011 (38:20 Md. R. 1204); February 26, 2018 (45:4 Md. R. 207) Regulation .02 repealed effective February 23, 2009 (36:4 Md. R. 355) Regulation .03A amended as an emergency provision effective January 1, 2005 (32:2 Md. R. 144); amended permanently effective June 6, 2005 (32:11 Md. R. 983) Regulation .03 repealed and new Regulation .03 adopted as an emergency provision effective July 1, 2008 (35:15 Md. R. 1346); adopted permanently effective August 25, 2008 (35:17 Md. R. 1489) Regulation .03 amended as an emergency provision effective June 30, 2013 (40:15 Md. R. 1227); amended permanently effective October 14, 2013 (40:20 Md. R. 1653) Regulation .03 amended effective February 16, 2015 (42:3 Md. R. 317) Regulation .03A amended effective September 20, 2010 (37:19 Md. R. 1284); October 3, 2011 (38:20 Md. R. 1204) Regulation .03A, C amended effective February 26, 2018 (45:4 Md. R. 207) Regulation .03A, D amended effective July 1, 2009 (36:10 Md. R. 717); February 18, 2013 (40:3 Md. R. 219) Regulation .03-1 adopted effective July 1, 2009 (36:10 Md. R. 717) Regulation .03-1 amended effective February 16, 2015 (42:3 Md. R. 317) Regulation .03-1B amended as an emergency provision effective June 30, 2013 (40:15 Md. R. 1227); amended permanently effective October 14, 2013 (40:20 Md. R. 1653) Regulation .04 repealed and new Regulation .04 adopted as an emergency provision effective July 1, 2008 (35:15 Md. R. 1346); adopted permanently effective August 25, 2008 (35:17 Md. R. 1489) Regulation .04A, B amended effective February 16, 2015 (42:3 Md. R. 317) Regulation .04B amended effective November 14, 2022 (49:23 Md. R 997) Regulation .04B, C amended effective July 1, 2009 (36:10 Md. R. 717) Regulation .05 amended effective February 18, 2013 (40:3 Md. R. 219) Regulation .05A amended effective January 6, 2005 (31:26 Md. R. 1865) Regulation .06 amended effective July 1, 2009 (36:10 Md. R. 717) Regulation .06 repealed effective February 16, 2015 (42:3 Md. R. 317) Regulation .09 adopted effective January 25, 2010 (37:2 Md. R. 69) Regulation .10 adopted effective August 3, 2015 (42:15 Md. R. 1016)