Code of Maryland Regulations › Title 14 - INDEPENDENT AGENCIES › Subtitle 35 - MARYLAND HEALTH BENEFIT EXCHANGE › Chapter 14.35.01 - General Provisions › Section 14.35.01.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this
				subtitle, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Advance payments of the premium tax
				credit" means payment of the federal tax credits authorized by
				26 U.S.C. §
											36B and its implementing regulations, which
				are provided on an advance basis to an eligible individual enrolled in a
				qualified health plan through the Exchange under § 1412 of the Affordable
				Care Act.
(2) "Advanced Premium Tax
				Credit (APTC)" has the meaning stated in
				45 CFR §
											155.20.
(3) 'Affordable Care Act (ACA) " means the
				Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148),
				as amended, including by the Health Care and Education Reconciliation Act of
				2010 (Pub. L.
				111-152), and the regulations issued under
				it.
(4) "Authorized carrier" means
				a carrier that the Exchange certifies is authorized to offer a qualified plan
				in the Exchange under COMAR 14.35.15.
(5) "Board" has the meaning stated in
				Insurance Article, §
										31-101, Annotated Code of
				Maryland.
(6) "Bronze coverage
				level" means the level of coverage described under § 1302(d)(1)(A) of the
				ACA.
(7) "CARES" means the case
				management data system that tracks eligibility for Medicaid and other social
				services.
(8) "Carrier" has the
				meaning set forth in Insurance Article §
										31-101(c),
				Annotated Code of Maryland.
(9)
				"Catastrophic plan" means a qualified health plan described in § 1302(e)
				of the ACA.
(10) "Certification
				standard" means a process, procedure, requirement, or condition of
				participation in the Exchange under COMAR 14.35.15 or COMAR 14.35.16.
(11) "Commissioner" means the Maryland
				Insurance Commissioner.
(12) Cost
				Sharing.
(a) "Cost sharing" means any
				expenditure required by or on behalf of an enrollee with respect to covered
				benefits.
(b) "Cost sharing"
				includes deductibles, coinsurance, copayments, or similar charges.
(c) "Cost sharing" does not include premiums,
				balance billing amounts for non-network providers, and spending for non-covered
				services.
(13) "
				Cost-sharing reductions (CSR)" means reductions in cost sharing for an eligible
				individual enrolled in a silver level plan through the Exchange or for an
				individual who is an Indian enrolled in a QHP through the Exchange.
(14) "Coverage" means insurance through which
				benefits are provided.
(15)
				"Department" means the Department of Health and Mental Hygiene.
(16) "Dependent" has the meaning stated in
				26 CFR §
											54.9801-2 with respect to eligibility for
				coverage under an individual or SHOP QHP because of a relationship to a
				qualified individual or enrollee.
(17) "Eligibility determination" means a
				decision by the Exchange about an applicant's eligibility to enroll in a QHP or
				insurance affordability program or terminate a qualified individual's
				enrollment in a QHP or insurance affordability program.
(18) "Enrollee" means a qualified individual,
				or qualified employee, who is enrolled in a qualified plan through the
				Individual or SHOP Exchange.
(19)
				"Enrollment" means the qualified individual's coverage in a qualified plan,
				catastrophic plan, or insurance affordability program through the
				Exchange.
(20) "Exchange" has the
				meaning stated in Insurance Article §
										31-101(e),
				Annotated Code of Maryland.
(21)
				"Exchange annual training" means the yearly training administered to certified
				navigators, licensed navigators, application counselors, and authorized
				producers by the Exchange as part of its training program.
(22) "Gold coverage level" means the level of
				coverage described under § 1302(d)(1)(C) of the ACA.
(23) "Grace period" means the period of time
				during which a carrier is prohibited from terminating an enrollee's enrollment
				in a qualified plan, as specified in:
(a)
				Insurance Article, §
											15-1315(c)
				-(e), Annotated Code of Maryland, if the enrollee is receiving advanced premium
				tax credits;
(b) Insurance Article,
				§
											15-209, Annotated Code of
				Maryland, for insurers due to non-payment of premium;
(c) COMAR
				31.10.25.04C, for
				non-profit health service plans;
(d) COMAR
				31.12.07.05D, for
				HMOs;
(e) COMAR
				31.12.04.05A, for
				dental plan organizations;
(f)
				COMAR 31.11.10.041 for insurers and non-profit health service plans offering
				small employer coverage in health benefit plans; or
(g) COMAR 31.12.07.041, for HMOs offering
				small employer coverage in health benefit plans.
(24) "Health benefit plan " has the meaning
				stated in Insurance Article, §
										31-101, Annotated Code of
				Maryland.
(25) "HHS" means the
				federal Department of Health and Human Services.
(26) "Individual Exchange" has the meaning
				stated in Insurance Article §
										31-101(h),
				Annotated Code of Maryland.
(27)
				"Individual Exchange Navigator" has the meaning stated in Insurance Article
				§
										31-101(i),
				Annotated Code of Maryland.
(28)
				"Individual Exchange Navigator Certification" has the meaning stated in
				Insurance Article §
										31-101(j),
				Annotated Code of Maryland.
(29)
				"Individual Exchange Navigator Entity" has the meaning stated in Insurance
				Article §
										31-101(k),
				Annotated Code of Maryland.
(30)
				"Insurance Producer" has the meaning stated in Insurance Article §
										1-101(u),
				Annotated Code of Maryland.
(31)
				"Insurance Producer Authorization" has the meaning stated in Insurance Article
				§
										31-101(m),
				Annotated Code of Maryland.
(32)
				"JAIL MATCH" means the data system containing information about incarcerated
				individuals within the State.
(33)
				"limited cost sharing plan variation" means the cost-sharing reduction
				variation of a QHP described in
				45 CFR §
											156.420(b) (2).
(34) "Managed Care Program" has the meaning
				stated in COMAR
				10.09.62.01B(100).
(35) "Maryland Children's Health Program
				(MCHP)" has the meaning stated in COMAR
				10.09.43.02B.
(36) "Maryland Insurance
				Administration" means the insurance administration for the State established
				under Insurance Article, §
										2-101, Annotated Code of
				Maryland.
(37) "Medicaid" has the
				meaning stated in COMAR
				10.09.24.02B(32).
(38) "Minimum essential coverage (MEC) " has
				the meaning stated in 26 USC
				§
											5000A(f) and the
				corresponding regulation under
				26CFR §
											1.5000A-2(a).
(39) "Navigator Entity" means Individual
				Exchange Navigator Entity.
(40)
				"Open Enrollment Period" means the annual period during which a qualified
				individual may enroll in coverage through the Exchange, including the initial
				open enrollment period as stated in
				45 CFR §
											155.20.
(41) "Plain language" has the meaning stated
				in § 1311(e)(3)(b) of the Affordable Care Act.
(42) "Plan variation" means a zero cost
				sharing plan variation, a limited cost sharing plan variation, or a silver plan
				variation.
(43) "Platinum coverage
				level" means the level of coverage described under § 1302(d)(1)(D) of the
				ACA.
(44) "Product" has the meaning
				stated in 45 CFR §
											154.102.
(45) "Qualified dental plan (QDP) " has the
				meaning stated in Insurance Article, §
										31-101, Annotated Code of
				Maryland.
(46) "Qualified employee"
				means an employee who has been determined eligible to enroll in a qualified
				plan through the SHOP Exchange.
(47) "Qualified health plan (QHP) " has the
				meaning stated in Insurance Article, §
										31-101, Annotated Code of
				Maryland.
(48) "Qualified
				Individual" has the meaning stated in Insurance Article, §
										31-101(s),
				Annotated Code of Maryland.
(49)
				"Qualified plan" has the meaning stated in Insurance Article, §
										31-101, Annotated Code of
				Maryland.
(50) "SHOP Exchange" has
				the meaning stated in Insurance Article, §
										31-101, Annotated Code of
				Maryland.
(51) "Silver coverage
				level" means the level of coverage described under § 1302(d)(1)(B) of the
				ACA.
(52) "Silver plan variation"
				means any of the cost-sharing reduction plan variations of the standard silver
				QHP under 45 CFR §
											156.420(a).
(53) "Single, streamlined application form"
				means the eligibility application for Medicaid, MCHP, qualified health plan,
				stand-alone dental plan, APTC, or CSR through the Exchange.
(54) "Special enrollment period " means the
				period during which a qualified individual, dependent, or enrollee, who
				experiences certain qualifying events may enroll in, or change enrollment in, a
				QHP through the Exchange outside of the annual open enrollment
				periods.
(55) "Stand-alone dental
				plan (SADP)" means a qualified dental plan that meets the requirements under
				45 CFR §
											155.1065(a).
(56) "Zero cost sharing plan variation "
				means the cost-sharing reduction plan variation of a QHP under
				45 CFR §
											156.420(b)(1).