Md. Code Regs. 31.17.03.02

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.17.03.02 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Administrator" means:

(a) A person that is registered as an administrator under Insurance Article, Title 8, Subtitle 3, Annotated Code of Maryland; or

(b) A carrier.

(2) "Board" means the Board of Directors for the Maryland Health Insurance Plan.

(3) "Carrier" means:

(a) An authorized insurer that provides health insurance in the State;

(b) A nonprofit health service plan that is licensed to operate in the State; or

(c) A health maintenance organization that is licensed to operate in the State.

(4) "Commission" means the Health Services Cost Review Commission.

(5) "Creditable coverage" has the meaning stated in Insurance Article, § 15-1301(f), Annotated Code of Maryland.

(6) "Date of adoption" means the earlier of:

(a) A judicial decree of adoption; or

(b) The assumption of custody, pending adoption, of a prospective adoptive child by a prospective adoptive parent.

(7) "Employer sponsored plan" has the meaning stated in Insurance Article, § 15-1301(h), Annotated Code of Maryland.

(8) "Fund" means the Maryland Health Insurance Plan Fund.

(9) "Grace period" means the period of 30 days following the due date of a premium, other than the first premium payable by an individual applying for coverage under the Plan, during which an individual may pay the premium to the Plan administrator and coverage continues under the Plan, without lapse.

(10) "Health benefit plan" has the meaning stated in Insurance Article, § 15-1301(k), Annotated Code of Maryland.

(11) "Hospital" means each hospital in the State for which rates are established by the Commission.

(12) Medically Uninsurable Individual.

(a) "Medically uninsurable individual" means an individual who is a resident of the State and who:

(i) Provides evidence that, for health reasons, a carrier has refused to issue substantially similar coverage to the individual;

(ii) Provides evidence that, for health reasons, a carrier has refused to issue substantially similar coverage to the individual, except at a rate that exceeds the Plan rate;

(iii) Is an eligible individual under Insurance Article, § 15-1301, Annotated Code of Maryland;

(iv) Has a history of or suffers from a medical or health condition under COMAR 31.17.02.02B(2);

(v) Is eligible for the tax credit for health insurance costs under §35 of the Internal Revenue Code; or

(vi) Is a dependent of an individual who is a medically uninsurable individual under §B(12) (a)(i)-(v) of this regulation.

(b) "Medically uninsurable individual" does not include an individual who is eligible for coverage under:

(i) The federal Medicare program;

(ii) The Maryland Medical Assistance Program;

(iii) The Maryland Children's Health Program; or

(iv) An employer-sponsored group health insurance plan that includes benefits comparable to Plan benefits, unless the individual is eligible for the tax credit for health insurance costs under §35 of the Internal Revenue Code.

(13) "Member" means an individual covered under the Plan.

(14) "Plan" means the Maryland Health Insurance Plan.

(15) "Plan administrator" means the administrator selected by the Board to administer the Plan.

(16) Preexisting Condition.

(a) "Preexisting condition" means a condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the date of enrollment for the Plan.

(b) "Preexisting condition" does not include pregnancy or congenital or birth defects of a newborn child.

(17) Substantially Similar Coverage.

(a) "Substantially similar coverage" means coverage under any:

(i) Contract providing hospital, medical, or surgical benefits on an expense incurred basis issued by an insurer;

(ii) Contract issued by a nonprofit health service plan;

(iii) Contract issued by a health maintenance organization; or

(iv) Employer-sponsored plan that provides health benefits to the employees of the employer.

(b) "Substantially similar coverage" does not include one or more, or any combination of the following:

(i) Coverage only for accident or disability insurance;

(ii) Coverage issued as a supplement to liability insurance;

(iii) Coverage only for travel insurance;

(iv) Liability insurance, including general liability insurance and automobile liability insurance;

(v) Workers' Compensation or similar insurance;

(vi) Automobile medical payment insurance;

(vii) Credit-only insurance; or

(viii) Coverage for on-site medical clinics.

(c) "Substantially similar coverage" does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the health plan:

(i) Limited scope dental or vision benefits;

(ii) Limited scope prescription drug benefits;

(iii) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these benefits;

(iv) Coverage only for a specified disease or illness; or

(v) Hospital indemnity or other fixed indemnity insurance.

(d) "Substantially similar coverage" does not include coverage listed under §B(17)(a) of this regulation if:

(i) The carrier is willing to issue the coverage only with a waiver rider for a specific condition or conditions; or

(ii) The coverage has annual out-of-pocket expenses for deductibles, co-payments, and other amounts, but not premiums, that exceed the amount of annual out-of-pocket expenses allowed for a high deductible plan as defined by §223(c)(2)(A) of the Internal Revenue Code, and as adjusted for inflation.

Md. Code Regs. 31.17.03.02

Regulations .02 adopted as an emergency provision effective April 8, 2003 (30:9 Md. R. 609); emergency text amended effective July 1, 2003 (30:16 Md. R. 1072); adopted permanently effective December 22, 2003 (30:25 Md. R. 1851)
Regulation .02B amended effective February 22, 2010 (37:4 Md. R. 343); August 9, 2010 (37:16 Md. R. 1060); January 7, 2013 (39:26 Md. R. 1666)