Chapter 03. Group Health Insurance — Continuation of Coverage of Surviving Spouses
Regulation .01 Purpose.LinkCopy Citation
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 surviving spouses and dependent children.
Regulation .02 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Applicable change in status” means the death of the insured.
(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” means that the:
(a)
Payment of benefits is based in whole or in part on the charge made by the provider; or
(b)
Services are directly provided without additional charge except for any deductible or copayment specified in the policy;
(c)
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;
(d)
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 covered under a group policy for a period of not less than 3 months.
(7)
“Qualified secondary beneficiary” means, with respect to an 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)
A dependent child.
(8)
“Self-insured group health benefit program or plan” means a program or plan furnished by an employer for the benefit of its employees providing hospital, surgical, medical, 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.
Regulation .03 Applicability.LinkCopy Citation
A.
This chapter is 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 by a health maintenance organization certified under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.
B.
This chapter is applicable to any policy or contract issued on or after the effective date of this chapter, beginning with the date of issue of the policy or contract.
C.
This chapter is applicable to any policy or contract issued before the effective date of this chapter, 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 this chapter.
Regulation .04 Eligibility.LinkCopy Citation
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.
Regulation .05 Coverage Provided.LinkCopy Citation
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 qualified secondary beneficiary 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 will 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 elect to 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 this chapter.
Regulation .06 Conditions of Coverage.LinkCopy Citation
A.
In order to receive the benefits provided under the group contract, a surviving spouse of the insured employee shall elect coverage not later than 45 days after the applicable change in status if a request is made for coverage under the group contract under which the insured employee is covered on the date of the applicable change in status. The coverage shall be retroactive to the applicable change in status.
B.
The request to the employer under §A of this regulation shall be in writing and signed by the qualified secondary beneficiary.
C.
Costs to Secondary Beneficiary.
(1)
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 change in status.
(3)
The entire cost to the employer may include a reasonable administrative fee not to exceed 2 percent of the amount permitted under §C(2) of this regulation.
(4)
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.
(5)
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.
D.
Due Date of Premium.
(1)
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.
(2)
At the time of the request referred to in §A of this regulation, payment will be due on the date of request. At the date of the request, 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 request is made.
Regulation .07 Termination.LinkCopy Citation
Coverage for a qualified secondary beneficiary will terminate on the earliest of any of the following:
A.
18 months after the date of the applicable change in status;
B.
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:
(1)
The group contract or the self-insured program or plan is on an expense-incurred basis; and
(2)
The eligibility does not result from the provisions of these regulations;
C.
The date on which the qualified secondary beneficiary becomes entitled to benefits under Title XVIII of the Social Security Act;
D.
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;
E.
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;
F.
The effective date of an election by a qualified secondary beneficiary to no longer be covered under the group contract; or
G.
The premium due date on which the qualified secondary beneficiary fails to make timely payment of any amount required under Regulation .06C of this chapter.
Regulation .08 Conversion and Continuation — Repealed.LinkCopy Citation
Regulation .09 Notification Requirements.LinkCopy Citation
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 this chapter, to which this chapter is applicable, shall be amended in accordance with this chapter not later than the date of applicability stated in Regulation .03C of this chapter.
Regulation .10 Election Statement.LinkCopy Citation
The form which a qualified secondary beneficiary shall use to elect coverage under these regulations shall be in language substantially as indicated in this regulation:
To _____________________________________________________________________________________________
(name of employer)
The employee ____________________________________________________________________________________
(name of employee)
Whose Social Security number was ____________________________ died on ____________________________________
(date od death)
This is to advise that _______________________________________________________________________________
____________________________________________________________________________________________
(name or names of qualified secondary beneficiaries)
who were covered as qualified dependents of the employee under the employer's group health insurance contract elect(s) to continue to be covered under that contract beginning with the date of death.
Date of Application: ________________________________
Signature of Qualified
Secondary Beneficiary: _____________________________________________________________________________
Mailing Address of
Secondary Beneficiary: _______________________________________________________________________________
Regulation .11 Termination Statement.LinkCopy Citation
The termination statement shall be in language substantially as indicated in this regulation:
To _____________________________________________________________________________________________
(name of employer)
This is to advise that _______________________________________________________________________________
_______________________________________________________________________________________________
(name or names of qualified secondary beneficiaries)
is/are no longer to be covered under our group health insurance contract effective ________________________________
(date)
The reason for this termination is ______________________________________________________________________
_________________________________________________________________________________________________
(reason)
Date: ___________________________
____________________________________________________________________________________________
(signature of qualified secondary beneficiary)
Chapter annotations
Authority: Insurance Article, §§2-109, 14-124(b), 15-407—15-409, and 15-412; Health-General Article, §19-703; Annotated Code of Maryland
History: Effective date: December 14, 1987 (14:25 Md. R. 2659)
History: Chapter recodified from COMAR 09.30.83 to COMAR 31.11.03 effective September 7, 1998 (25:18 Md. R. 1439)
History: Regulation .08 repealed effective June 22, 2015 (42:12 Md. R. 764)