# COMAR Title 31 — Maryland Insurance Administration

## Subtitle 11 — Health Insurance — Group

### Chapter 02 — Group Health Insurance — Continuation of Coverage of Divorced Spouses

**Authority:** Insurance Article, §§2-109, 15-407—15-409, and 15-412; Health-General Article, §19-703; Annotated Code of Maryland

**Administrative History:** Effective date: September 19, 1988 (15:19 Md. R. 2247)

**Administrative History:** Chapter recodified from COMAR 09.30.77 to COMAR 31.11.02 effective September 7, 1998 (25:18 Md. R. 1439)

**Administrative History:** Regulation .08 repealed effective June 22, 2015 (42:12 Md. R. 764)

#### Regulation .01 Purpose.

*COMAR 31.11.02.01*

The purpose of this chapter is to provide standards for implementing requirements of the Insurance Article and of Health-General Article, Annotated Code of Maryland, with respect to providing or continuing coverage for certain divorced spouses and dependent children.

#### Regulation .02 Definitions.

*COMAR 31.11.02.02*

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

B. Terms Defined.

  (1) “Applicable change in status” means the divorce of the insured and the insured's spouse.

  (2) “Dependent child” means an individual who:

    (a) Is a child of the insured; and

    (b) Either was covered under the group contract as a qualified or eligible dependent of the insured immediately preceding the applicable change in status, or was born to a qualified secondary beneficiary after the applicable change in status.

  (3) “Employer” means an employer, an association of employers, or a trust sponsored by an employer or an association of employers to whom a group contract has been issued.

  (4) Expense-Incurred Basis.

    (a) “Expense-incurred Basis” means that the:

      (i) Payment of benefits is based in whole or in part on the charge made by the provider; or

      (ii) Services are directly provided without additional charge except for any deductible or copayment specified in the policy.

    (b) Policies or contracts issued on an expense-incurred basis include, but are not limited to:

      (i) Health maintenance organization coverage;

      (ii) A policy which provides for the cost of a semiprivate hospital room;

      (iii) A policy which provides coverage for a semiprivate hospital room subject to a daily deductible;

      (iv) A policy which provides coverage for a semiprivate hospital room but which is subject to a copayment;

      (v) A policy which provides a daily hospital benefit of more than $100;

      (vi) A policy which pays medical-surgical benefits on a usual and customary basis.

    (c) The following policies or contracts are not to be regarded as being on an expense-incurred basis:

      (i) A policy which provides a daily hospital benefit of a fixed dollar amount not in excess of $100 per day;

      (ii) A policy which provides only medical-surgical benefits in accordance with a fixed schedule of fees.

  (5) “Group policy” or “group contract” means an insurance contract issued or delivered in this State which provides hospital, surgical, medical, or major medical coverage issued to an employer for the benefit of its employees by:

    (a) An authorized insurer in accordance with Insurance Article, §15-302, Annotated Code of Maryland;

    (b) A nonprofit health service plan authorized under Insurance Article, §§14-108—14-111, Annotated Code of Maryland; or

    (c) A health maintenance organization authorized under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.

  (6) “Insured” means an employee who is a resident of this State and is covered under a group policy.

  (7) “Qualified secondary beneficiary” means, with respect to the insured, an individual other than the insured who is a:

    (a) Beneficiary under the group contract as the spouse of the insured for at least the 30-day period immediately preceding an applicable change in status; or

    (b) Dependent child.

  (8) “Self-insured group health benefit program or plan” means a program or plan furnished by an employer for the benefit if its employees providing hospital, medical, surgical, or major medical benefits on an expense-incurred basis similar to benefits which could be provided under a group health insurance policy.

  (9) “Termination statement” means a written notice of an event specified in Regulation .07 of this chapter provided to an employer on a form containing language prescribed by the Commissioner, or in substantially similar language, which is signed by the insured and:

    (a) A qualified secondary beneficiary; or

    (b) Accompanied by a signed and sworn affidavit of the insured verifying the factual content of the statement.

#### Regulation .03 Applicability.

*COMAR 31.11.02.03*

A. These regulations shall be applicable to all group health insurance policies or contracts issued or delivered in this State to the employer of the insured which provide hospital, surgical, medical, or major medical benefits on an expense-incurred basis whether issued by a nonprofit health service plan or by any other insurer and to all group policies or contracts issued or delivered in this State to an employer of an insured by a health maintenance organization certified under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.

B. These regulations shall be applicable to any policy or contract issued on or after the effective date of these regulations, beginning with the date of issue of the policy or contract.

C. These regulations shall be applicable to any policy or contract issued before the effective date of these regulations, beginning on the first annual renewal date or the first anniversary of the date of issue of the policy or contract occurring on or next following the effective date of these regulations.

#### Regulation .04 Eligibility.

*COMAR 31.11.02.04*

A. Beginning with an applicable change in status and until the occurrence of an event described in Regulation .07 of this chapter, the qualified secondary beneficiary shall be entitled to the benefits provided under the group contract.

B. Section A of this regulation may not be applicable to any period during which the insured is not covered by a group contract.

#### Regulation .05 Coverage Provided.

*COMAR 31.11.02.05*

A. The coverage provided to a qualified secondary beneficiary shall be identical to the coverage which would have been provided under the group contract for the benefit of the qualified secondary beneficiary if the individual had remained an eligible dependent of the insured employee and there had been no applicable change in status.

B. If modifications are made in the employer's group contract, the coverage provided to the qualified secondary beneficiary shall be correspondingly modified.

C. If the employer transfers from one group contract to another, the coverage provided the qualified secondary beneficiary shall be transferred to that provided under the new group contract.

D. If the employer provides various hospital, surgical, medical, or major medical coverages under one or more group contracts, a qualified secondary beneficiary may not choose less than all of the benefits provided unless the insured employee would have had the option of making such a choice for an eligible dependent if there had been no applicable change in status.

E. The benefits to be provided under the group contract shall be in no respect less favorable than those required by these regulations.

#### Regulation .06 Conditions of Coverage.

*COMAR 31.11.02.06*

A. In order to receive the benefits provided under the group contract, an insured employee, or the divorced spouse of the insured employee, shall notify the employer of the applicable change in status not later than:

  (1) 60 days after the applicable change in status if on the date of the applicable change in status the employee is covered under the employer's group contract or under another group contract issued to the same employer replacing that contract. The coverage shall be retroactive to the applicable change in status.

  (2) 30 days after the date the insured employee becomes eligible for coverage under a group contract issued to another employer, if the insured employee becomes covered under the new employer's group contract after the applicable change in status. The coverage shall be retroactive to the date of eligibility.

B. The request to the employer under §A of this regulation shall be in writing and signed by the insured.

C. Costs Paid to Employer.

  (1) The insured employee or the qualified secondary beneficiary shall pay to the employer the employer's entire cost for the coverage to be provided.

  (2) The entire cost to the employer includes the employer's customary contribution as well as the contribution customarily required of an employee if there were no applicable changes in status.

  (3) If the insurer quotes rates to the employer separately for individual coverage and for dependent coverage, the payment to be made on behalf of the qualified secondary beneficiary shall be the rate quoted for dependents.

  (4) If the insurer quotes a family rate which would normally include an employee and eligible dependents, the amount payable on behalf of the qualified secondary beneficiary shall be the difference between the family rate and the rate payable for an individual employee who is not covered for dependents.

  (5) If, in connection with a divorce, there is a court order or an agreement between the insured and the insured's spouse as to the allocation of the cost of the insurance coverage between the insured employee and the spouse, payment to the employer shall be made in accordance with the terms of the court order or the agreement.

D. Payment to the employer for the cost of the coverage is due and shall be paid on or before the first day of each month for which coverage is to be provided unless the employer agrees in writing to payment at a later date. The following apply:

  (1) If the employer customarily collects employee contributions under the group contract on a quarterly basis, the required payment is due and shall be paid on or before the first day of each quarter for which coverage is to be provided.

  (2) At the time of the notice referred to in §A of this regulation, payment will be due on the date notice is given. On that date the amount of payment due shall be the accumulated charges to cover the period beginning with the effective date of the coverage to be provided to the end of the month in which the notice is given.

#### Regulation .07 Termination.

*COMAR 31.11.02.07*

A. Coverage for a qualified secondary beneficiary will terminate when the coverage under the group contract terminates with respect to the insured employee.

B. Even though the insured employee continues to be covered under the group contract, coverage with respect to any individual qualified secondary beneficiary shall terminate on the date of occurrence of any of the following:

  (1) The date on which the qualified secondary beneficiary becomes eligible for hospital, surgical, medical, or major medical benefits under any insured group contract or any health maintenance organization group contract or any self-insured group health benefit program or plan provided the:

    (a) Group contract or the self-insured program or plan is on an expense-incurred basis, and

    (b) Eligibility does not result from the provisions of these regulations;

  (2) The date on which the insured becomes entitled to benefits under Title XVIII of the Social Security Act;

  (3) The date on which a qualified secondary beneficiary who is a dependent child would no longer have been covered under the group contract if there had been no applicable change in status;

  (4) The date of remarriage of an individual who is a qualified secondary beneficiary by reason of having been the divorced spouse of the insured employee;

  (5) The date on which the qualified secondary beneficiary becomes insured under a non-group policy or contract or under a non-group health maintenance organization contract which provides coverage for hospital, surgical, medical, or major medical benefits on an expense-incurred basis;

  (6) The effective date of an election by a qualified secondary beneficiary to no longer be covered under the group contract;

  (7) The date the employer receives a duly executed notice of termination, or the effective date of the notice if later;

  (8) The premium due date on which the premium payable to the employer by or on behalf of the qualified secondary beneficiary is not timely made.

#### Regulation .08 Conversion and Continuation — Repealed.

*COMAR 31.11.02.08*

#### Regulation .09 Notification Requirements.

*COMAR 31.11.02.09*

A. Each group contract to which these regulations are applicable shall include a statement as provided in §B of this regulation.

B. The statement shall disclose the availability of the benefits provided under these regulations and shall provide a summary of the eligibility requirements, the duration and general description of the benefits.

C. Each group contract issued before the effective date of these regulations, to which these regulations are applicable, shall be amended in accordance with these regulations not later than the date of applicability stated in Regulation .03B of this chapter.

#### Regulation .10 Termination Statement.

*COMAR 31.11.02.10*

A. The termination statement shall be in language substantially as indicated in this regulation.

B. If the termination statement is signed by the insured and a qualified secondary beneficiary:

C. If the termination statement is to be signed only by the insured: