Md. Code Regs. 31.17.03.14

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

Section 31.17.03.14 - Eligibility Requirements

A. Except as provided in §§D-F of this regulation, an individual is eligible for coverage under the Plan if the individual is:

(1) A medically uninsurable individual; and

(2) Satisfies any applicable residency requirement in §C of this regulation.

B. Eligibility for Employer-Sponsored Group Health Insurance Plan.

(1) For purposes of determining whether an individual who is eligible for coverage under an employer-sponsored group health insurance plan is a medically uninsurable individual under Regulation .02B(12)(b)(iv) of this chapter, benefits provided by an employer-sponsored group health insurance plan are not comparable to benefits provided by the Maryland Health Insurance Plan if:

(a) The employer-sponsored group health insurance plan does not provide coverage for any one of the following major categories of treatments, services, or supplies:

(i) Blood and blood products;

(ii) Chemotherapy and radiation therapy;

(iii) Diabetic equipment and services;

(iv) Dialysis;

(v) Durable medical equipment and disposable medical supplies;

(vi) Emergency services and urgent care;

(vii) Family planning services;

(viii) Habilitative care;

(ix) Home health care;

(x) Hospice care;

(xi) Hospital inpatient services;

(xii) Infertility testing and diagnosis;

(xiii) Maternity care;

(xiv) Mental health and substance abuse services;

(xv) Organ and tissue transplants;

(xvi) Outpatient services;

(xvii) Physician services;

(xviii) Prescription drugs;

(xix) Preventive services;

(xx) Prosthetics;

(xxi) Rehabilitation services; or

(xxii) Skilled nursing facility;

(b) The employer-sponsored group health insurance plan imposes an annual limit on the cost or number of covered treatments, services, or supplies that is less than 50 percent of any annual limit on the cost or number of covered treatments, services, or supplies imposed by the Maryland Health Insurance Plan; or

(c) The only option or options available under the employer-sponsored group health insurance plan have 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.

(2) Benefits provided by an employer-sponsored group health insurance plan are not considered to be not comparable to benefits provided by the Maryland Health Insurance Plan solely because the employer-sponsored group health insurance plan:

(a) Excludes coverage for a particular treatment, service, procedure, device, or type of supply that is covered by the Plan;

(b) Imposes a temporary preexisting condition exclusion at a time when the Plan does not impose a preexisting condition exclusion; or

(c) Imposes a temporary preexisting condition exclusion that is different in scope or duration from a preexisting condition exclusion that is imposed by the Plan.

C. Residency Requirements.

(1) Unless an individual satisfies the requirements of §C(2) of this regulation, an individual shall be a resident of Maryland for at least 6 months in order to be eligible for the Plan.

(2) An individual may not be required to satisfy the 6-month residency requirement found in §C(1) of this regulation if the individual is a resident of the State and:

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

(b) Applies for coverage under the Plan within 63 days of losing coverage under another state's high-risk pool; or

(c) Is eligible for the tax credit for health insurance costs under §35 of the Internal Revenue Code.

D. Except as provided in §E of this regulation, an individual is not eligible for Plan coverage if:

(1) The individual's coverage under the Plan was terminated for nonpayment of premium; and

(2) The individual applies for Plan coverage within 12 months of the individual's Plan coverage being terminated for nonpayment of premium.

E. An individual may not be denied Plan coverage under §D of this regulation, if the individual:

(1) Becomes covered under other substantially similar coverage within 63 days of terminating Plan coverage;

(2) Is terminated from the substantially similar coverage referenced in §E(1) of this regulation for a reason other than nonpayment of premium by:

(a) The individual; or

(b) A family member of the individual; and

(3) Applies for coverage under the Plan within 63 days of being terminated from the substantially similar coverage referenced in §E(1) of this regulation.

F. An individual is not eligible for Plan coverage if the individual's coverage under the Plan has been previously terminated due to fraud or intentional misrepresentation.

Md. Code Regs. 31.17.03.14

Regulations .14 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 .14 amended effective May 4, 2009 (36:9 Md. R. 654); February 22, 2010 (37:4 Md. R. 343)