<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".14" citation="COMAR 31.17.03.14" title_num="31" subtitle_num="17" chapter_num="03" heading="Eligibility Requirements.">
  <paragraph num="A.">
    <text>Except as provided in §§D—F of this regulation, an individual is eligible for coverage under the Plan if the individual is:</text>
    <paragraph num="(1)">
      <text>A medically uninsurable individual; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Satisfies any applicable residency requirement in §C of this regulation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Eligibility for Employer-Sponsored Group Health Insurance Plan.</text>
    <paragraph num="(1)">
      <text>For purposes of determining whether an individual who is eligible for coverage under an employer-sponsored group health insurance plan is a medically uninsurable individual under Regulation .02B(12)(b)(iv) of this chapter, benefits provided by an employer-sponsored group health insurance plan are not comparable to benefits provided by the Maryland Health Insurance Plan if:</text>
      <paragraph num="(a)">
        <text>The employer-sponsored group health insurance plan does not provide coverage for any one of the following major categories of treatments, services, or supplies:</text>
        <paragraph num="(i)">
          <text>Blood and blood products;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Chemotherapy and radiation therapy;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Diabetic equipment and services;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Dialysis;</text>
        </paragraph>
        <paragraph num="(v)">
          <text>Durable medical equipment and disposable medical supplies;</text>
        </paragraph>
        <paragraph num="(vi)">
          <text>Emergency services and urgent care;</text>
        </paragraph>
        <paragraph num="(vii)">
          <text>Family planning services;</text>
        </paragraph>
        <paragraph num="(viii)">
          <text>Habilitative care;</text>
        </paragraph>
        <paragraph num="(ix)">
          <text>Home health care;</text>
        </paragraph>
        <paragraph num="(x)">
          <text>Hospice care;</text>
        </paragraph>
        <paragraph num="(xi)">
          <text>Hospital inpatient services;</text>
        </paragraph>
        <paragraph num="(xii)">
          <text>Infertility testing and diagnosis;</text>
        </paragraph>
        <paragraph num="(xiii)">
          <text>Maternity care;</text>
        </paragraph>
        <paragraph num="(xiv)">
          <text>Mental health and substance abuse services;</text>
        </paragraph>
        <paragraph num="(xv)">
          <text>Organ and tissue transplants;</text>
        </paragraph>
        <paragraph num="(xvi)">
          <text>Outpatient services;</text>
        </paragraph>
        <paragraph num="(xvii)">
          <text>Physician services;</text>
        </paragraph>
        <paragraph num="(xviii)">
          <text>Prescription drugs;</text>
        </paragraph>
        <paragraph num="(xix)">
          <text>Preventive services;</text>
        </paragraph>
        <paragraph num="(xx)">
          <text>Prosthetics;</text>
        </paragraph>
        <paragraph num="(xxi)">
          <text>Rehabilitation services; or</text>
        </paragraph>
        <paragraph num="(xxii)">
          <text>Skilled nursing facility;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>The employer-sponsored group health insurance plan imposes an annual limit on the cost or number of covered treatments, services, or supplies that is less than 50 percent of any annual limit on the cost or number of covered treatments, services, or supplies imposed by the Maryland Health Insurance Plan; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The only option or options available under the employer-sponsored group health insurance plan have annual out-of-pocket expenses for deductibles, co-payments, and other amounts, but not premiums, that exceed the amount of annual out-of-pocket expenses allowed for a high deductible plan as defined by §223(c)(2)(A) of the Internal Revenue Code, and as adjusted for inflation.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Benefits provided by an employer-sponsored group health insurance plan are not considered to be not comparable to benefits provided by the Maryland Health Insurance Plan solely because the employer-sponsored group health insurance plan:</text>
      <paragraph num="(a)">
        <text>Excludes coverage for a particular treatment, service, procedure, device, or type of supply that is covered by the Plan;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Imposes a temporary preexisting condition exclusion at a time when the Plan does not impose a preexisting condition exclusion; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Imposes a temporary preexisting condition exclusion that is different in scope or duration from a preexisting condition exclusion that is imposed by the Plan.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Residency Requirements.</text>
    <paragraph num="(1)">
      <text>Unless an individual satisfies the requirements of §C(2) of this regulation, an individual shall be a resident of Maryland for at least 6 months in order to be eligible for the Plan.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>An individual may not be required to satisfy the 6-month residency requirement found in §C(1) of this regulation if the individual is a resident of the State and:</text>
      <paragraph num="(a)">
        <text>Is an eligible individual under Insurance Article, §15-1301, Annotated Code of Maryland;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Applies for coverage under the Plan within 63 days of losing coverage under another state's high-risk pool; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Is eligible for the tax credit for health insurance costs under §35 of the Internal Revenue Code.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Except as provided in §E of this regulation, an individual is not eligible for Plan coverage if:</text>
    <paragraph num="(1)">
      <text>The individual's coverage under the Plan was terminated for nonpayment of premium; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The individual applies for Plan coverage within 12 months of the individual's Plan coverage being terminated for nonpayment of premium.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>An individual may not be denied Plan coverage under §D of this regulation, if the individual:</text>
    <paragraph num="(1)">
      <text>Becomes covered under other substantially similar coverage within 63 days of terminating Plan coverage;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Is terminated from the substantially similar coverage referenced in §E(1) of this regulation for a reason other than nonpayment of premium by:</text>
      <paragraph num="(a)">
        <text>The individual; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A family member of the individual; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Applies for coverage under the Plan within 63 days of being terminated from the substantially similar coverage referenced in §E(1) of this regulation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>An individual is not eligible for Plan coverage if the individual's coverage under the Plan has been previously terminated due to fraud or intentional misrepresentation.</text>
  </paragraph>
</regulation>