Md. Code Regs. 14.35.07.16

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

Section 14.35.07.16 - Special Enrollment Period-Violation of Material Provision Through the Individual Exchange

A. Prior to January 1, 2020, an enrollee or an enrollee's dependent shall be 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)(5) occurs.

B. Effective January 1, 2020, an enrollee or an enrollee's dependent is eligible for a special enrollment period if the enrollee or the enrollee's dependent:

(1) Demonstrates, as determined by the Individual Exchange in collaboration and coordination with the Maryland Insurance Administration, that the carrier of the QHP in which the enrollee or dependent is enrolled substantially violated a material provision of its contract in relation to the enrollee or the enrollee's dependent; and

(2) Notifies the Exchange or the Maryland Insurance Administration of the alleged violation by the later of:

(a) 30 days of the violation; or

(b) 30 days of when the enrollee or dependent reasonably should have known about the violation.

C. Notification to the Individual Exchange under §B(2) of this regulation shall be satisfied if the enrollee or the enrollee'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.

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

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

F. The effective date of coverage for an enrollee or an enrollee'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 material violation;

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

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

G. 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 violation of a material provision of the contract in relation to the enrollee or the enrollee's dependent.

Md. Code Regs. 14.35.07.16

Regulation .16 adopted effective 46:5 Md. R. 306, eff. 3/11/2019