Md. Code Regs. 14.35.07.15

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

Section 14.35.07.15 - Special Enrollment Period-Misconduct Through the Individual Exchange

A. Prior to January 1, 2020, a qualified individual or qualified individual's dependent is eligible for a 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, a qualified individual or qualified individual's dependent is eligible for a special enrollment period if:

(1) The Individual Exchange determines, in collaboration and coordination with the Maryland Insurance Administration that, as a result of misconduct on the part of the Individual Exchange, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities, the qualified individual or qualified individual's dependent:

(a) Was not enrolled in a QHP;

(b) Was not enrolled in the QHP selected by the qualified individual, enrollee, or dependent; or

(c) Is eligible for, but is not receiving APTC or CSR; and

(2) The qualified individual or qualified individual's dependent notifies the Individual Exchange or the Maryland Insurance Administration of the alleged misconduct by the later of:

(a) 30 days of the misconduct; or

(b) 30 days of when the qualified individual reasonably should have known about the misconduct.

C. Misconduct under this regulation means the failure of an officer, employee, or agent of the Individual Exchange, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities to comply with applicable standards set forth in COMAR 14.35 or other applicable State or federal laws as determined by the Individual Exchange, or the Maryland Insurance Administration.

D. Notification to the Individual Exchange under §B(2) 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. Notification to the Maryland Insurance Administration under §B(2) of this regulation shall be satisfied if the qualified individual or the qualified individual's dependent files a complaint with the Maryland Insurance Administration.

F. Effective January 1, 2020, the length of the special enrollment period shall be 30 days from the date that the Individual Exchange notifies the qualified individual or the qualified individual's dependent that the qualified individual or the qualified individual's dependent is eligible for a special enrollment period under this regulation.

G. 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 §F of this regulation.:

(1) Shall be determined by the Individual Exchange as appropriate based on the circumstances of the misconduct;

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

(3) May be retroactive or prospective depending on the nature of the misconduct.

H. The Individual Exchange's determination that an individual is eligible for a special enrollment period under this regulation may be made prior to the completion of the Maryland Insurance Administration's review of the alleged misconduct.

Md. Code Regs. 14.35.07.15

Regulation .15 adopted effective 46:5 Md. R. 306, eff. 3/11/2019