Md. Code Regs. 14.35.07.14

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

Section 14.35.07.14 - Special Enrollment Period - Error, Misrepresentation, or Inaction Through the Individual Exchange

A. Prior to January 1, 2020, a qualified individual or a qualified individual's dependent shall be eligible for the special enrollment period set forth in 45 CFR § 155.420(c)(3) if the triggering event set forth in 45 CFR § 155.420(d)(4) occurs.

B. Effective January 1, 2020, as evaluated and determined by the Individual Exchange, a qualified individual or qualified individual's dependent is eligible for a special enrollment period when the individual or dependent's enrollment or non-enrollment in a QHP is:

(1) Unintentional, inadvertent, or erroneous; and

(2) The result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Individual Exchange its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities.

C. Effective January 1, 2020, a qualified individual or a qualified individual's dependent shall notify the Individual Exchange of the alleged error, misrepresentation, or inaction by the later of:

(1) 30 days of the alleged error, misrepresentation, or inaction; or

(2) 30 days from when the qualified individual reasonably should have known about the alleged error, misrepresentation, or inaction.

D. Notification to the Individual Exchange under §C of this regulation shall be satisfied if the qualified individual or qualified individual's dependent provides notice:

(1) To an Individual Exchange-certified navigator, an Individual Exchange-authorized broker or an Individual Exchange-certified consolidated service center representative; and

(2) Using any of the methods of communication listed under Regulation .03B of this chapter.

E. Effective January 1, 2020, the length of the special enrollment period shall be 60 days from the date that the Individual Exchange notifies the qualified individual or qualified individual's dependent of their eligibility for a special enrollment period under this regulation.

F. The effective date of coverage for a qualified individual or the qualified individual's dependent who is determined eligible for a special enrollment period under this regulation and selects a QHP during the special enrollment period under §E of this regulation:

(1) Shall be a date determined by the Individual Exchange as appropriate based on the circumstances of the error, misrepresentative, or inaction;

(2) Shall be no earlier than the date the qualified individual's or qualified individual's dependent's coverage would have begun or continued but for the error, misrepresentation, or inaction; and

(3) May be retroactive or prospective depending on the nature of the error, misrepresentation, or inaction.

G. Plan Display Errors.

(1) A qualified individual, an enrollee, or their dependent is eligible for a special enrollment period if their decision to purchase a QHP through the Exchange was influenced by a material error related to plan benefits, cost sharing, service area, or premium.

(2) Notwithstanding §§C and D of this regulation, the burden of proof for an error under this section may not fall on the qualified individual or qualified individual's dependent.

(3) The length of the special enrollment period under this section shall adhere to the guidance in §E of this regulation.

(4) The effective date of coverage under this section shall adhere to the guidance in §F of this regulation.

Md. Code Regs. 14.35.07.14

Regulation .14 adopted effective 46:5 Md. R. 306, eff. 3/11/2019; amended effective 51:3 Md. R. 154, eff. 2/19/2024.