Md. Code Regs. 14.35.17.03

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

Section 14.35.17.03 - Eligibility for Receipt of Reinsurance Payments

A. Except as provided in §B of this regulation, a qualified health plan is eligible to receive reinsurance payments from the State Reinsurance Program, provided that the qualified health plan is offered by a carrier that:

(1) Is authorized to offer individual non-Medigap health benefit plans in Maryland;

(2) Complies with the assessment under Insurance Article, § 6-102.1, Annotated Code of Maryland; and

(3) Meets all obligations set forth in the Carrier Business Agreement.

B. The following health benefit plans are not eligible to receive reinsurance payments:

(1) Grandfathered health benefit plans as defined in § 1251 of the Affordable Care Act;

(2) Health benefit plans that are not required to submit reinsurance contributions under Insurance Article, § 6-102.1, Annotated Code of Maryland;

(3) Group health insurance plans, including but not limited to those identified in Insurance Article, § 15-1202, Annotated Code of Maryland;

(4) Short-term, limited duration insurance plans, including but not limited to those identified in Insurance Article, § 15-1301, Annotated Code of Maryland; and

(5) Association health plans, including but not limited to those offered by associations identified in Insurance Article, § 15-1301, Annotated Code of Maryland.

C. Carrier State Reinsurance Program Accountability Report. For each year a carrier which offers a reinsurance-eligible plan participates in the State Reinsurance Program, the carrier shall submit to the Board a report on a date no later than that provided in the Annual letter to Issuers, to be made publically available on the Individual Exchange website upon review of the Board, detailing carrier action to manage the costs and utilization of enrollees whose claims are reimbursable under the State Reinsurance Program. At minimum, the report shall include information related to the following:

(1) The initiatives and programs the carrier administers to manage cost and utilization of enrollees whose claims are reimbursable under the State Reinsurance Program in a narrative summary format;

(2) The total population of enrollees whose claims are reimbursable under the State Reinsurance Program, the allocation of these enrollees across each of the initiatives and programs identified in §C(1) of this regulation, and the allocation of these enrollees who do not participate in the initiatives and programs identified in §C(1) of this regulation;

(3) The effectiveness of the initiatives and programs identified in §C(1) of this regulation as measured by the estimated reduction of claims and utilization by the enrollees identified in §C(1) of this regulation;

(4) The actions the carrier will take to improve on the effectiveness estimates identified in §C(3) of this regulation;

(5) The estimated savings to the State Reinsurance Program based upon the effectiveness identified in §C(3) of this regulation;

(6) The estimated rate impact of the initiatives and programs identified in §C(1) of this regulation;

(7) The methodology utilized to determine which programs to include in §C(1) of this regulation, estimated effectives in §C(3) of this regulation, and estimated savings to the State Reinsurance Program in §C(5) of this regulation; and

(8) Population health initiatives and outcomes for Individual Exchange enrollment.

Md. Code Regs. 14.35.17.03

Regulation .03 adopted effective 46:5 Md. R. 309, eff. 3/11/2019