Md. Code Regs. 14.35.16.11

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

Section 14.35.16.11 - Qualified Health Plan Denial, Suspension, and Revocation of Certification and Other Remedies

A. If the Exchange determines that a carrier has failed to comply with this chapter, Insurance Article, Title 31, Annotated Code of Maryland, or any other federal or State laws or regulations applicable to carrier offerings in the Exchange that are not otherwise specified in Insurance Article, § 31-115(k), Annotated Code of Maryland, the Exchange may initiate one or more of the following actions against the carrier:

(1) Deny certification for participation in the Exchange;

(2) Suspend the carrier's certification for participation in the Exchange;

(3) Revoke the carrier's certification for participation in the Exchange; or

(4) Another remedy defined under §D of this regulation.

B. Subject to the contested case hearing provisions of State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland, and the limitations stated in Insurance Article, § 31-115(k), Annotated Code of Maryland, the Exchange may deny certification to a health benefit plan, or suspend or revoke the certification of a qualified health plan, based on a finding that the health benefit plan or qualified health plan does not satisfy requirements or has otherwise violated standards for certification that are established under this regulation and interim policies adopted by the Exchange, and not otherwise under the regulatory and enforcement authority of the Commissioner, including requirements and standards related, but not limited, to:

(1) Enrollment;

(2) Essential community providers;

(3) Complaints and grievances involving the Individual Exchange;

(4) Network adequacy;

(5) Quality;

(6) Transparency;

(7) Race, ethnicity, language, interpreter need, and cultural competency (RELICC);

(8) Plan service area, including demographics;

(9) Accreditation;

(10) Authorization of the plan's sponsoring carrier; and

(11) Fair marketing standards developed jointly by the Individual Exchange and the Commissioner.

C. Instead of or in addition to denying, suspending, or revoking plan certification, the Exchange may impose other remedies or take other actions, and to the extent not otherwise under the regulatory and enforcement authority of the Commissioner, including:

(1) Requiring a corrective action to remedy a violation of or failure to comply with standards for certification; and

(2) Imposing a penalty not exceeding $5,000 for each violation of or failure to comply with standards for certification.

D. In determining the amount of a penalty under §C of this regulation, the Exchange shall consider:

(1) The type, severity, and duration of the violation;

(2) Whether the plan or carrier knew or should have known of the violation;

(3) The extent to which the plan or carrier has a history of violations; and

(4) Whether the plan or carrier corrected the violation as soon as they knew or should have known of the violation.

E. The penalties available to the Exchange under this regulation shall be in addition to any criminal or civil penalties imposed for fraud or other violation under any other State or federal law.

Md. Code Regs. 14.35.16.11

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