Md. Code Regs. 14.35.07.12

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

Section 14.35.07.12 - Special Enrollment Periods - Loss of Minimum Essential Coverage or Termination of Other Specified Coverage Through the Individual Exchange

A. A qualified individual and, when specified in this regulation, an enrollee, a qualified individual's dependent, or an enrollee's dependent are eligible for a special enrollment period for loss of minimum essential coverage or other specified coverage if:

(1) The qualified individual or the qualified individual's dependent loses minimum essential coverage;

(2) A qualified individual or a qualified individual's dependent was enrolled in coverage through a non-calendar year group health plan, individual health insurance coverage, or qualified small employer health reimbursement arrangement (as defined in § 9831(d)(2) of the Internal Revenue Code) and the policy or plan year ends in the middle of the calendar year, even if the qualified individual or the qualified individual's dependent has the option to renew the coverage;

(3) A qualified individual or the qualified individual's dependent loses pregnancy-related coverage described in COMAR 10.09.24.03A(2) and 45 CFR § 155.420(d)(1)(iii) or loses access to health care services through coverage provided to a pregnant women's unborn child based on the definition of a child in 42 CFR § 457.10; or

(4) A qualified individual or the qualified individual's dependent loses the medically needy coverage under COMAR 10.09.24.03E.

B. A qualified individual and, when specified in this regulation, an enrollee, a qualified individual's dependent, or an enrollee's dependent are eligible for a special enrollment period for loss of minimum essential coverage or other specified coverage under circumstances including, but not limited to:

(1) The qualified individual or the qualified individual's dependent loses eligibility for qualifying eligible employer-sponsored minimum coverage that is not COBRA continuation coverage for reasons including:

(a) Legal separation;

(b) Divorce;

(c) Cessation of dependent status;

(d) Death of an employee;

(e) Termination of employment;

(f) Reduction in the number of hours of employment;

(g) The individual's coverage does not provide benefits to individuals who no longer reside, live, or work in a service area and the individual no longer resides, lives, or works in the service area;

(h) The individual incurs a claim that would meet or exceed a lifetime limit on all benefits;

(i) The individual's plan no longer offers any benefits to the class of similarly situated individuals that includes the individual;

(j) The employer terminates employer contributions to the individual's coverage; or

(k) The qualified individual or qualified individual's dependent, who is enrolled in an employer-sponsored plan, is determined newly eligible for APTC because the employer-sponsored plan is no longer considered minimum essential coverage set forth in 26 CFR § 1.36B-2(c)(3), including as a result of the qualified individual's employer discontinuing or changing available coverage within the next 60 days, if the qualified individual or qualified individual's dependent is permitted by the employer and applicable federal laws to terminate enrollment in the employer-sponsored plan;

(2) A qualified individual or the qualified individual's dependent loses eligibility for employer-sponsored coverage that is COBRA continuation coverage or continuation coverage under State law because:

(a) The individual exhausted COBRA continuation coverage or continuation coverage under State law;

(b) The individual's employer was paying all or part of the premiums and completely ceased contributions to the individual or dependent's coverage; or

(c) A governmental entity was subsidizing coverage and completely ceased contributions to the individual or dependent's coverage; or

(3) An enrollee or an enrollee's dependent loses coverage in a QHP because the QHP is decertified.

C. Loss of minimum essential coverage does not include termination or loss due to:

(1) Failure to pay premiums on a timely basis, including failure to pay COBRA premiums prior to expiration of COBRA coverage;

(2) A change in eligibility status under 45 CFR § 155.315(f)(5) because the individual does not meet the requirement specified under Regulation .05 of this chapter;

(3) An authorized carrier's valid rescission of coverage;

(4) A loss in coverage from a short-term limited duration insurance plan as stated in Insurance Article, § 15-1301(s), Annotated Code of Maryland; or

(5) A loss in coverage from an association health plan as stated in Insurance Article, § 15-1301(c), Annotated Code of Maryland that does not meet the definition for minimum essential coverage as stated in Insurance Article, § 15-1301(p), Annotated Code of Maryland.

D. The date of loss of minimum essential coverage or other coverage is the date the qualified individual, the enrollee, the qualified individual's dependent, or the enrollee's dependent:

(1) Loses eligibility for minimum essential coverage under the previous plan; or

(2) The coverage under §A(1) - (4) of this regulation terminates.

E. To be eligible for a special enrollment period under this regulation, a qualified individual, an enrollee, a qualified individual's dependent, or an enrollee's dependent shall:

(1) Report the loss of minimum essential coverage or the termination of coverage under §A(1) - (4) of this regulation;

(2) Select a QHP:

(a) Up to 60 days before or within 90 days after the loss of minimum essential coverage through the Maryland State Medicaid Program or the Maryland Children's Health Insurance Program (CHIP), including the Maryland Children's Health Program (MCHP) Premium, on August 1, 2024, and beyond; or

(b) Up to 60 days before or within 60 days after the loss of any other form of minimum essential coverage or the termination of coverage; and

(3) Provide attestation or documentary evidence from an employer, carrier, legal/court proceeding, public health coverage program, death certificate, or the qualified individual that, together, indicates the date of coverage loss and the qualified individuals losing coverage.

F. Enrollment in a QHP selected by a qualified individual, an enrollee, or a qualified individual's dependent during a special enrollment period for loss of minimum essential coverage or termination of coverage under §A(1)-(4) of this regulation shall be effective on:

(1) The first day of the month following the loss of minimum essential coverage or termination of coverage if the Individual Exchange receives the QHP selection before the loss of minimum essential coverage or the coverage terminates;

(2) The first day of the month after the Individual Exchange receives the QHP selection if the Individual Exchange receives the QHP selection after the loss of minimum essential coverage or the coverage terminates; or

(3) Notwithstanding §F(1) and (2), at the option of the consumer, the first day of the month in which the triggering event occurs if the loss of minimum essential coverage occurs mid-month and the plan selection is made on or before the last day of the month preceding the triggering event.

G. The eligibility for the special enrollment period under §A(4) of this regulation shall only be available once per calendar year for the qualified individual and the qualified individual's dependent.

H. Notwithstanding the standards outlined in this regulation and in Regulations .13-.19 of this chapter, if a qualified individual is eligible for advance payments of the premium tax credit or cost-sharing reductions, the advance payment of the premium tax credit or the cost-sharing reduction shall be effective on the qualified individual's enrollment date.

Md. Code Regs. 14.35.07.12

Regulation .12 adopted effective 46:5 Md. R. 306, eff. 3/11/2019; amended effective 49:12 Md. R.642, eff. 6/13/2022; amended effective 51:3 Md. R. 154, eff. 2/19/2024.