Md. Code Regs. 14.35.07.19

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

Section 14.35.07.19 - Special Enrollment Period - Other

A. An enrollee or an enrollee's dependent enrolled in the same plan is eligible for a special enrollment period if the enrollee or enrollee's dependent:

(1) Is determined newly eligible or ineligible for APTC; or

(2) Has a change in eligibility for cost-sharing reductions.

B. A qualified individual or a qualified individual's dependent is eligible for a special enrollment period if the qualified individual or qualified individual's dependent:

(1) Experiences a decrease in household income;

(2) Is newly determined eligible by the Individual Exchange for APTC; and

(3) Had minimum essential coverage as described in 26 CFR § 1.5000A-1(b) for one or more days during the 60 days preceding the date of the financial change.

C. A qualified individual, a qualified individual's dependent, or an enrollee's dependent is eligible for a special enrollment period through the Maryland Easy Enrollment Health Insurance Program as codified in Md. Code, Ins. §31.202 if they indicate on a state tax return that they:

(1) Attest to not having health care coverage; and

(2) Authorize the Comptroller of Maryland to share information from the qualified individual's tax return with the Maryland Health Benefit Exchange.

D. A qualified individual or qualified individual's dependent is eligible for a special enrollment period if the qualified individual or qualified individual's dependent is confirmed to be pregnant by a health care practitioner.

E. A qualified individual who is an Indian, or becomes a dependent of an Indian, may enroll in a QHP or change from one QHP to another, no more than once per month.

F. A qualified individual or a qualified individual's dependent is eligible for a special enrollment period if the qualified individual or qualified individual's dependent who was not previously a U.S. citizen, a U.S. national, or lawfully present in the U.S. becomes a U.S citizen, a U.S. national, or lawfully present in the U.S.

G. A qualified individual or a qualified individual's dependent is eligible for a special enrollment period if the qualified individual or qualified individual's dependent who was previously incarcerated becomes newly eligible for a QHP due to satisfying the requirements under 45 CFR § 155.306(a)(2).

H. A qualified individual or qualified individual's dependent is eligible for a special enrollment period if the qualified individual receives a certificate of exemption under Regulation .20 of this chapter for a hardship based on the eligibility standards set forth in 45 CFR § 155.605(d)(i)-(iii) for a month or months during the coverage year, and based on the circumstances of the hardship attested to, the qualified individual is no longer eligible for a hardship exemption within a coverage year but outside of an open enrollment period.

I. A qualified individual or a qualified individual's dependent is eligible for a special enrollment period if a qualified individual with a certificate of exemption under Regulation .20 of this chapter for a hardship based on the eligibility standards for an exemption, as set forth in 45 CFR § 155.620(b), the change resulting from a redetermination is implemented, and the qualified individual or the qualified individual's dependent is no longer eligible for an exemption.

J. Individual Coverage Health Reimbursement Arrangements and Qualified Small Employer Health Reimbursement Arrangements.

(1) A qualified individual, an enrollee, a qualified individual's dependent, or an enrollee's dependent is eligible for a special enrollment period if they newly gain access to an individual coverage health reimbursement arrangement (HRA) (as defined in 45 CFR § 146.123(b)) or are newly provided a qualified small employer health reimbursement arrangement (QSEHRA) (as defined in § 9831(d)(2) of the Internal Revenue Code).

(2) The triggering event is the first day on which coverage for the qualified individual, enrollee, qualified individual's dependent, or enrollee's dependent under the individual coverage HRA can take effect, or the first day on which coverage under the QSEHRA takes effect.

(3) A qualified individual, an enrollee, a qualified individual's dependent, or an enrollee's dependent qualifies for this special enrollment period regardless of whether they were previously offered or enrolled in an individual coverage HRA or previously provided a QSEHRA, if the qualified individual, enrollee, qualified individual's dependent, or enrollee's dependent is not enrolled in the individual coverage HRA or covered by the QSEHRA on the day immediately prior to the triggering event.

K. A qualified individual or qualified individual's dependent is eligible for a special enrollment period if the qualified individual or qualified individual's dependent:

(1) Applies for coverage on the Exchange during the annual open enrollment period or due to a qualifying event;

(2) Is assessed by the Exchange as potentially eligible for Medicaid or MCHP; and

(3) Is determined ineligible for Medicaid or MCHP by the Department either after open enrollment has ended or more than 60 days after the qualifying event.

L. A qualified individual, an enrollee, a qualified individual's dependent or an enrollee's dependent is eligible for a special enrollment period if the qualified individual or qualified individual's dependent experiences a change or triggering event not included in this regulation under 45 CFR § 155.420.

M. A qualified individual, an enrollee, a qualified individual's dependent, or an enrollee's dependent is eligible to enroll during any month of the year if:

(1) They are eligible for APTC;

(2) Their household income does not exceed 150 percent of the federal poverty line; and

(3) The tax filer's applicable percentage for purposes of calculating the premium assistance amount, as defined in § 36B(b)(3)(A) of the Internal Revenue Code, is set at zero.

N. Eligibility Windows.

(1) A qualified individual, an enrollee, a qualified individual's dependent, or an enrollee's dependent shall notify the Individual Exchange of the change in circumstances and select a QHP within the following time frames:

(a) For §§A, B, F, and K of this regulation, 60 days after the date of the event that triggers the special enrollment period;

(b) For §§E and G - I of this regulation, 60 days before or after the date of the event that triggers the special enrollment period;

(c) For §C of this regulation (Maryland Easy Enrollment Health Insurance Program), 35 days after the date specified on the SEP notification letter sent to the qualified individual;

(d) For §D of this regulation (pregnancy), 90 days after the date of confirmation of pregnancy by a health care practitioner; and

(e) For §J of this regulation, 60 days before the triggering event, unless the HRA or QSEHRA was not required to provide the notice setting forth its terms to such individual or enrollee at least 90 days before the beginning of the plan year, as specified in 45 CFR § 146.123(c) (6), 26 CFR § 54.9802-4(c)(6), and 29 CFR § 2590.702-2(c)(6) or § 9831(d)(4) of the Internal Revenue Code, as applicable, in which case the qualified individual, enrollee, or dependent of the individual or enrollee has 60 days before or after the triggering event to select a QHP.

(2) If a qualified individual, an enrollee, a qualified individual's dependent or an enrollee's dependent did not receive timely notice of an event that triggers eligibility for a special enrollment period under this chapter, and otherwise was reasonably unaware that a triggering event described in this chapter occurred, the Exchange shall allow the qualified individual, enrollee, or, when applicable, their dependent to select a new plan within 60 days of the date that they knew, or reasonably should have known, of the occurrence of the triggering event.

O. Enrollment in a QHP selected by a qualified individual, an enrollee, the qualified individual's dependent, or the enrollee's dependent during a special enrollment period under this regulation shall be effective:

(1) For the special enrollment period under §A of this regulation (newly eligible or ineligible for APTC), §E of this regulation (qualified individual or dependent is an Indian) and §F of this regulation (changes in citizenship status):

(a) The first day of the month after the Individual Exchange receives the QHP selection when the plan has been selected between the first and the 15th of the month; or

(b) The first day of the following month after the Individual Exchange receives the QHP selection when the plan has been selected between the 16th and the last day of the month;

(2) For the special enrollment period under §D of this regulation (pregnancy):

(a) The first day of the month in which pregnancy is confirmed, including retroactive coverage dates; or

(b) The first day of the month in which the QHP selection is received by the Individual Exchange;

(3) For the special enrollment period under §G of this regulation (previously incarcerated) and §J of this regulation (newly eligible for an individual coverage HRA or a QSEHRA):

(a) The first day of the month following the triggering event for QHP selections received by the Individual Exchange before the release date or before the triggering event; or

(b) The first day of the following month for QHP selections received by the Individual Exchange after the release date or the triggering event;

(4) For the special enrollment period under §K of this regulation (Medicaid or MCHP ineligibility determination), an appropriate date determined by the Exchange based on the circumstances of the special enrollment period; and

(5) For special enrollment periods other than the special enrollment periods specified in §O(1)-(4), the first day of the month following the date that the Individual Exchange receives the QHP selection.

P. Notwithstanding §O, in the case of untimely notice of a triggering event as described in §N(2) of this regulation, a qualified individual, enrollee, qualified individual's dependent, or enrollee's dependent shall have the option of the earliest effective date that would have been available based on the applicable triggering event under this chapter.

Md. Code Regs. 14.35.07.19

Regulation .19 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.