Chapter 03. Operation and Administration of the Plan

A person that is registered as an administrator under Insurance Article, Title 8, Subtitle 3, Annotated Code of Maryland; or

A carrier.

An authorized insurer that provides health insurance in the State;

A nonprofit health service plan that is licensed to operate in the State; or

A health maintenance organization that is licensed to operate in the State.

A judicial decree of adoption; or

The assumption of custody, pending adoption, of a prospective adoptive child by a prospective adoptive parent.

“Medically uninsurable individual” means an individual who is a resident of the State and who:

“Medically uninsurable individual” does not include an individual who is eligible for coverage under:

“Preexisting condition” means a condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the date of enrollment for the Plan.

“Preexisting condition” does not include pregnancy or congenital or birth defects of a newborn child.

“Substantially similar coverage” means coverage under any:

“Substantially similar coverage” does not include one or more, or any combination of the following:

“Substantially similar coverage” does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the health plan:

“Substantially similar coverage” does not include coverage listed under §B(17)(a) of this regulation if:

The additional documentation that is required; and

The deadline set by the plan administrator for receipt of the additional documentation.

The plan administrator shall notify the applicant that the applicant has not demonstrated eligibility for the low-income subsidy and bill the applicant for standard Plan enrollment; and

The applicant shall reapply for a low-income subsidy if the applicant wishes to receive future consideration for a low-income subsidy.

In a form acceptable to the Board; and

That demonstrates continued eligibility for the low-income subsidy.

Discontinue granting the low-income subsidy; and

Establish a waiting list of individuals who are eligible for the low-income subsidy.

The insurance producer assists an individual in completing an application for the Plan; and

The individual is accepted by the Plan.

The employer-sponsored group health insurance plan does not provide coverage for any one of the following major categories of treatments, services, or supplies:

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

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.

Excludes coverage for a particular treatment, service, procedure, device, or type of supply that is covered by the Plan;

Imposes a temporary preexisting condition exclusion at a time when the Plan does not impose a preexisting condition exclusion; or

Imposes a temporary preexisting condition exclusion that is different in scope or duration from a preexisting condition exclusion that is imposed by the Plan.

Is an eligible individual under Insurance Article, §15-1301, Annotated Code of Maryland;

Applies for coverage under the Plan within 63 days of losing coverage under another state's high-risk pool; or

Is eligible for the tax credit for health insurance costs under §35 of the Internal Revenue Code.

The individual; or

A family member of the individual; and

Has 3 months of prior creditable coverage;

Is eligible for the tax credit for health insurance costs under §35 of the Internal Revenue Code; and

Applies for the Plan coverage within 63 days after losing prior creditable coverage.

For a dependent child, other than a child who is unable to self support due to physical or mental incapacity, when the dependent child reaches the limiting age found in the member's certificate of coverage; or

The member ceases to be a resident of the State.

The member or the member's covered dependent has performed an act or practice that constitutes fraud;

The member has made an intentional misrepresentation of material fact in the application for Plan coverage;

The member becomes covered under other coverage that is substantially similar to the coverage of the Plan;

The member becomes eligible for employer sponsored coverage that includes benefits comparable to Plan benefits, unless the member is eligible for the tax credit for health insurance costs under §35 of the Internal Revenue Code; or

The member becomes eligible for coverage under Medicare, the Maryland Medical Assistance Program, or the Maryland Children's Health Program.

If the Plan administrator gives notice of termination before the 15th day of a month, at the end of that month; or

If the Plan administrator gives notice of termination on or after the 15th day of a month, at the end of the following month.