Md. Code Regs. 14.35.07.11

Current through Register Vol. 51, No. 24, December 2, 2024

Section 14.35.07.11 - Enrollment in a QHP or Insurance Affordability Program Through the Individual Exchange

A. A qualified individual may enroll in a QHP or an insurance affordability program under Regulation .02B(12)(c) and .02B(12)(d) of this chapter, through the Individual Exchange only during:

(1) The annual open enrollment period of the Individual Exchange, or

(2) A special enrollment period for which the Individual Exchange has determined that the qualified individual is eligible.

B. The annual open enrollment period for the Individual Exchange shall be:

(1) For the benefit year beginning on January 1, 2019, November 1, 2018 through December 15, 2018;

(2) For the benefit years beginning on January 1, 2020 and on January 1, 2021, November 1 through December 15 of the calendar year preceding the benefit year; and

(3) For the benefit years beginning on January 1, 2022 and after, November 1 of the calendar year preceding the benefit year through January 15 of the benefit year.

C. The Individual Exchange may modify or extend the annual open enrollment period each year with the approval of the Board of Trustees and consistent with 45 CFR § 155.410.

D. Coverage selected during an open enrollment period shall:

(1) For the benefit year beginning on January 1, 2019, be effective on:

(a) January 1, 2019, for QHP selections received by the Individual Exchange on or before December 15, 2018; and

(b) January 1, 2019, or later as determined by the Board of Trustees, for QHP selections received by the Individual Exchange on or after December 16, 2018 and on or before December 31, 2018 if the Board of Trustees modifies or extends the annual open enrollment period under Regulation .11C of this chapter; and

(2) For the benefit year beginning on January 1, 2020 and after, be effective on:

(a) January 1 for QHP selections received by the Individual Exchange on or before December 15 of the calendar year preceding the benefit year;

(b) January 1 or later, for QHP selections received by the Individual Exchange on or after December 16 and on or before December 31 of the calendar year preceding the benefit year if the Board of Trustees modifies or extends the annual open enrollment period under Regulation .11C of this chapter; and

(c) February 1 for QHP selections received by the Individual Exchange on or after January 1 or before January 15 of the benefit year.

E. If an individual enrolls in a QHP, the Individual Exchange shall promptly and without undue delay transmit to the carrier of the QHP the information necessary to enable the QHP's carrier to enroll the qualified individual in the QHP selected by the qualified individual, including:

(1) The qualified individual's selected QHP;

(2) The qualified individual's eligibility or change in eligibility for APTC or a CSRplan, if applicable;

(3) Whether the carrier should apply, remove, or change the total amount of the qualified individual's APTC, if applicable;

(4) The dollar amount of the APTC, if any;

(5) The advance payment amount of the CSRplan, if any; and

(6) The effective date of the QHP enrollment.

F. Payment of First Month's Premium.

(1) A qualified individual shall pay the first month's premium to the carrier of the QHP to effectuate enrollment in the QHP when the individual has:

(a) Enrolled in a QHP after coverage from a previous enrollment in a QHP the individual had was terminated;

(b) Enrolled for the first time in a QHP in the Individual Exchange; or

(c) Enrolled in a QHP offered by a different carrier of the same holding company in the Individual Exchange.

(2) The first month's premium payment to effectuate prospective coverage for QHP selections made during an annual open enrollment period or during a special enrollment period under Regulations .13E(4), .18D(1) - (2) and .19I of this chapter shall be due on a uniformly applied date specified by the authorized carrier of the QHP that is no earlier than the coverage effective date but no later than 30 calendar days from the coverage effective date.

(3) Effective January 1, 2020, the first month's premium payment to effectuate prospective coverage for QHP selections made during an annual open enrollment period or during a special enrollment period described in Regulations .13E( 4), .18D (1) - (2), and .19I of this chapter shall be due on a uniformly applied date specified by the authorized carrier of the QHP that is no earlier than the coverage effective date but no later than 30 calendar days from the coverage effective date.

(4) The first month's premium payment to effectuate prospective coverage for QHP selections made during a special enrollment period under Regulations .12F, .13E(1) and (3), .14F, .15G, .16F, .17F, .18D(3), and .19A of this chapter shall be due on a date specified by the authorized carrier of the QHP and uniformly applied that is no earlier than the coverage effective date or no later than 30 calendar days from the date the carrier receives the enrollment transaction from the Exchange or the coverage effective date, whichever is later.

(5) Effective January 1, 2020, the first month's premium payment to effectuate prospective coverage for QHP selections made during a special enrollment period described in Regulations .12F, .13E(1) and (3), .14F, .15G, .16F, .17F, .18D(3), and .19A of this chapter shall be due on a uniformly applied date specified by the authorized carrier that is no earlier than the coverage effective date or no later than 30 calendar days from the date the carrier receives the enrollment transaction from the Individual Exchange or the coverage effective date, whichever is later

(6) Payment to effectuate retroactive coverage shall include the premium due for all months of retroactive coverage and shall also include the full premium amount of the first prospective month of coverage.

(7) Payment to effectuate retroactive coverage for QHP selections made during a special enrollment period shall be due on a uniformly applied date specified by the authorized carrier that is no earlier than the coverage effective date and no later than 30 calendar days from the date the carrier receives the enrollment transaction from the Individual Exchange or the coverage effective date, whichever is later.

(8) Effective January 1, 2020, payment to effectuate retroactive coverage for QHP selections made during a special enrollment period under Regulations .13E(2), .14F, .15G, .16F, and .17F of this chapter shall be due on the first day of the first full prospective coverage month.

(9) An authorized carrier may choose to extend the premium due date under §F of this regulation if the carrier does so in a uniform and consistent manner for all similarly situated applicants.

G. Premium Payment Threshold Policy.

(1) An authorized carrier may establish a premium payment threshold policy.

(2) Under the premium payment threshold policy the authorized carrier may consider the individual or enrollee to have paid all amounts due if the enrollee pays an amount sufficient of the total premium owed equal to or greater than a level determined by the carrier.

(3) If an authorized carrier establishes a premium payment threshold policy, the authorized carrier shall:

(a) Determine a premium payment level that is reasonable; and

(b) Apply the premium payment level and the premium payment threshold policy in a uniform manner to all qualified individuals and enrollees.

(4) If a qualified individual satisfies the authorized carrier's premium payment threshold policy, the authorized carrier shall effectuate an enrollment based on payment of the initial premium payment under §F of this regulation;

(5) If an enrollee satisfies the authorized carrier's premium payment threshold policy, the authorized carrier may not:

(a) Trigger a grace period for non-payment of premium set forth in:

(i) Insurance Article, § 15-1315(c) -(e), Annotated Code of Maryland, if the enrollee is receiving APTC; or

(ii) Insurance Article, § 15-209, Annotated Code of Maryland (for insurers), COMAR 31.10.25.04C(for nonprofit health services plans), or COMAR 31.12.07.05D(for HMOs) if the enrollee is not receiving APTC; or

(b) Terminate the enrollment for non-payment of premium under 45 CFR § 155.430(b)(2)(H).

H. An authorized carrier shall accept and process an enrollment for a qualified individual that does not include a Social Security number.

I. The Individual Exchange shall maintain records of all enrollments through the Individual Exchange.

Md. Code Regs. 14.35.07.11

Regulation .11 adopted effective 46:5 Md. R. 306, eff. 3/11/2019; amended effective 49:12 Md. R.642, eff. 6/13/2022