Md. Code Regs. 17.04.13.09

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

Section 17.04.13.09 - Termination of Coverage

A. In this regulation, the following terms have the meanings indicated:

(1) Claim.

(a) "Claim" means a demand for payment or benefit under a plan, policy or contract by a covered individual under the Program, an insured, a third party, a provider, or a representative of any of them.

(b) "Claim" includes a demand made to the State, the Department, a contractor, or any representative or agent of the State, the Department, or a contractor in connection with the Program.

(2) Contractor.

(a) "Contractor" means a person, business, or organization under contract with the State or the Department to provide goods or services under the Program.

(b) "Contractor" includes a third-party administrator, insurer, carrier, or other agent, including a subcontractor of a third-party administrator, insurer, or carrier, that administers or processes claims or approves benefits and services in the Program.

(3) "Coverage" includes all coverage or benefits plans or options in which an individual is enrolled through the Program.

(4) "Department" means the Department of Budget and Management.

(5) "Director" means the individual appointed to manage the Employee Benefits Division or unit of the Department with primary responsibility for administering the Program.

(6) "False representation" means the knowing and willful:

(a) Concealing, falsifying, or omitting of a material fact;

(b) Making of a materially false or fraudulent statement; or

(c) Use of a document that contains a statement of material fact that the user knows to be false or fraudulent.

(7) Fraud.

(a) "Fraud" means the intentional perversion of the truth taken with the intent to gain something of value or to induce another to part with something of value.

(b) "Fraud" includes but is not limited to:

(i) The willful making of a false statement or a false representation; or

(ii) The impersonation of another.

(8) Health Care Service.

(a) "Health care service" means health or medical care procedures, goods, or services that:

(i) Provide testing, diagnosis, or treatment of human disease or dysfunction; or

(ii) Dispense drugs, medical devices, medical appliances, or medical goods for the treatment of human disease or dysfunction.

(b) "Health care service" includes any procedure, goods, or service that is a required, available, or covered benefit in any health, medical, prescription, or dental plan option provided through the Program.

(9) Provider.

(a) "Provider" means an individual, company, facility, organization, or other entity that supplies services or benefits that are covered under the Program.

(b) "Provider" includes, but is not limited to, a doctor, pharmacist, hospital, or other medical professional rendering services within their expertise.

(10) "Representation" means a statement and includes an acknowledgment, certification, claim, ratification, or report.

B. Scope of Termination of Coverage. The Secretary may terminate coverage in the Program of an individual otherwise eligible for coverage under Regulation .03 or .03-1 of this chapter using the procedures outlined in this regulation. Such termination may be:

(1) Permanent or for a period of time; and

(2) Of all Program coverage or of coverage in one or more benefits plans or benefits options.

C. Causes for Termination of Benefits. Program coverage may be terminated if a covered individual:

(1) Knowingly makes, uses, or causes to be made or used a false record, representation, or statement to get or attempt to get a claim paid or approved under the Program;

(2) Conspires to defraud the State or the Department by getting or attempting to get a false or fraudulent claim approved or paid under the Program;

(3) Knowingly gets or attempts to get a false or fraudulent claim paid or approved under the Program for an amount higher than the amount billed by the provider, paid to the provider, charged by the provider, or owed to the provider;

(4) Knowingly makes, uses, or causes to be made or used a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or other property under the Program;

(5) Knowingly makes a false or fraudulent claim for health care services under the Program;

(6) Knowingly obtains, attempts to obtain, or aids another individual in obtaining or attempting to obtain a drug product, medication, medical care, or other health care service, if the payment of all or part of the payment is or may be made under the Program:

(a) By fraud, deceit, false representation, or concealment;

(b) By counterfeiting or alteration of a prescription;

(c) By concealment of a material fact;

(d) By using a false name or a false address; or

(e) For purposes other than the legitimate treatment of the covered individual's medical condition;

(7) Knowingly enrolls, attempts to enroll, or aids another individual in enrolling or attempting to enroll in coverage under the Program if eligibility for coverage is not authorized under law, including but not limited to false representation concerning eligibility for Program coverage;

(8) Knowingly presents or causes to be presented to an officer, employee, or agent of the State or the Department, contractor, provider, or other person receiving State or Departmental funds a false or fraudulent claim for payment or benefit approval under the Program; or

(9) Commits or attempts to commit fraud in connection with the Program.

D. Process for Termination of Coverage.

(1) The Director shall investigate allegations, instances, or occurrences that may justify termination in the Program. To the extent it is not prohibited by applicable law, an investigation may include:

(a) Seeking or receiving information from:

(i) A provider;

(ii) A law enforcement agency, official, officer, or employee;

(iii) A contractor in the Program; or

(vi) The covered individual or the person who has elected coverage for the covered individual;

(b) Review or use of past claims history or medical information relevant to the covered individual; or

(c) Other steps that the Director determines are necessary to conclude whether there is cause for termination of coverage.

(2) Prior to concluding that there is cause for termination of coverage, the Director shall notify the covered individual of the investigation and provide the individual with the opportunity, lasting at least 14 days, to submit information relevant to the investigation.

(3) Upon concluding that there is cause for termination of coverage, the Director shall make a recommendation to the Secretary for a decision.

(4) Notice of Termination of Coverage.

(a) Prior to a termination of coverage described in §B of this regulation, the covered individual shall be provided with written notice of the termination and the cause for termination.

(b) The notice may include a demand for repayment of any monies paid by the State through the Program.

(c) The notice shall:

(i) Be issued at least 15 business days prior to the date termination will take effect;

(ii) In the case of a dependent, be provided as well to the individual, identified in Regulation .03A or .03-1 of this chapter, who elected coverage of the dependent;

(iii) Identify the cause for termination of coverage;

(iv) Identify the date on which coverage will terminate;

(v) Identify the scope of the termination;

(vi) Inform the covered individual whether continuation coverage is available; and

(vii) Be sent certified and regular mail to the last address on record with the Department for the covered individual.

(5) Appeal of Termination of Coverage.

(a) An employee covered by State Personnel and Pensions Article, Title 12, Annotated Code of Maryland, may file a grievance under that title related to any action taken pursuant to this regulation.

(b) Otherwise, an individual may request a hearing, to be held in accordance with COMAR 17.02.03, to challenge a termination of coverage taken pursuant to this regulation. The request shall be made in writing to the Secretary within 20 days of the date the individual received the notice of coverage termination. Such hearings, and the record, shall be closed to the extent that failure to close the hearing and protect the record will disclose protected health information, as such term is defined in 45 CFR § 160.103.

E. Departmental Action.

(1) In the event of the termination of Program coverage of an active employee, the Secretary shall notify the benefits coordinator of the employing agency of the termination of coverage; however, the notice may not include any description or explanation of the basis of the termination unless that disclosure is authorized pursuant to relevant confidentiality or protection of privacy laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all pertinent regulations (for example, 45 CFR Parts 160 and 164) promulgated pursuant to HIPAA.

(2) The Secretary or a designee shall refer the results of any investigation that an employee has made a false representation concerning eligibility for Program coverage of any individual or committed any activity identified in §C(7) of this regulation to the appointing authority, employing agency or employing satellite organization.

(3) The notice of termination may only be made if the false representation is or is contained in enrollment information available to the appointing authority, employing agency, or employing satellite organization in a personnel file or other employment materials. Such situations include when an employee presents to the appointing authority, employing agency, or employing satellite organization for submission to the Department a false, counterfeit, or altered birth certificate, marriage certificate, or affidavit that supports the enrollment of a dependent.

(4) The Department may seek repayment or restitution from the individual whose coverage has been terminated for cause as identified in §C of this regulation for the value of the payments made or benefits provided under the Program under such circumstances.

(5) In the case of the termination of coverage of an individual, identified in Regulation .03A(1)-(6), (8), (10), and (11) or .03-1 of this chapter, who is eligible to elect coverage for a dependent, the Program coverage of all covered dependents will also be terminated.

(6) The Department shall take steps to discontinue any payroll deduction or automatic contribution from a retirement allowance for coverage that has been terminated.

Md. Code Regs. 17.04.13.09

Regulation .09 adopted effective January 25, 2010 (37:2 Md. R. 69)