Md. Code Regs. 14.35.16.04

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

Section 14.35.16.04 - Qualified Health Plan Certification-Application

A. Each authorized carrier shall annually submit an application, in a form specified by the Annual Letter to Issuers, for each health benefit plan intended to be certified as a QHP to be offered on the Exchange.

B. A carrier shall submit a completed application, including all required information and submissions under this regulation, to the Exchange.

C. The Exchange shall notify a carrier of the application status within 45 days of receipt of a completed application.

D. If an application is determined incomplete, the Exchange shall notify a carrier of the application status within 45 days of the initial submission.

E. Information Submission.

(1) An authorized carrier shall submit an initial submission containing the information required under §§E and F of this regulation and Regulations .04 - .10 of this chapter as part of the application under §B of this regulation and detailed through the Annual Letter to Issuers.

(2) If requested by the Exchange, an authorized carrier shall submit a supplement to its initial submission under §E(1) of this regulation.

F. In accordance with Insurance Article, § 31-115(g)(2), Annotated Code of Maryland, upon request, an authorized carrier shall provide in its application a description of the health benefit plan, in plain language and in a form specified by the Annual Letter to Issuer, that includes:

(1) Claims payment policies and practices;

(2) Data on enrollment, disenrollment, number of claims denied (including in whole and in part), and rating practices, if applicable;

(3) Information on cost sharing and payments with respect to any out-of-network coverage; and

(4) Any other information as determined appropriate by the Exchange.

G. An authorized carrier shall provide in its application, in a form specified in the Annual Letter to Issuers, the following information about the health benefit plan:

(1) Plan, benefit, and cost sharing;

(2) Plan information for the renewal of QHP enrollment;

(3) Unified rate review template;

(4) Prescription drug cost sharing and formulary;

(5) Provider network;

(6) Service area, including justifications for partial county service areas;

(7) Rate and premiums;

(8) Actuarial information required to be submitted to the Exchange under 45 CFR § 155.1030(b);

(9) Provider directory data as specified in Regulation .07 of this chapter;

(10) Summaries of benefits and coverage, under 45 CFR § 147.200, for each cost-sharing reduction variation;

(11) Essential community providers contracted to participate within the health benefit plan's provider network; and

(12) Any other information the carrier would like to provide to the Exchange to supplement the application.

H. An authorized carrier shall comply with the rate and form review procedures, including review of compliance with essential health benefits requirements, established by the Commissioner.

I. Data and information submitted to the Exchange may be provided to the Commissioner, if requested, for consideration in the Commissioner's annual QHP rate and form review process.

J. The authorized carrier shall provide to the Exchange the rate justification forms filed with the Commissioner for each QHP certification application the authorized carrier submits to the Exchange.

Md. Code Regs. 14.35.16.04

Regulation .04 adopted effective 46:5 Md. R. 309, eff. 3/11/2019