Md. Code Regs. 14.35.01.02

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

Section 14.35.01.02 - Definitions

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) "Provider network" has the same meaning as "provider panel" as stated in COMAR 31.10.35.03B(7).

(46) "Qualified dental plan (QDP)" has the meaning stated in Insurance Article, § 31-101, Annotated Code of Maryland.

(47) "Qualified employee" means an employee who has been determined eligible to enroll in a qualified plan through the SHOP Exchange.

(48) "Qualified health plan (QHP)" has the meaning stated in Insurance Article, § 31-101, Annotated Code of Maryland.

(49) "Qualified Individual" has the meaning stated in Insurance Article, § 31-101(s), Annotated Code of Maryland.

(50) "Qualified plan" has the meaning stated in Insurance Article, § 31-101, Annotated Code of Maryland.

(51) "SHOP Exchange" has the meaning stated in Insurance Article, § 31-101, Annotated Code of Maryland.

(52) "Silver coverage level" means the level of coverage described under § 1302(d)(1)(B) of the ACA.

(53) "Silver plan variation" means any of the cost-sharing reduction plan variations of the standard silver QHP under 45 CFR § 156.420(a).

(54) "Single, streamlined application form" means the eligibility application for Medicaid, MCHP, qualified health plan, stand-alone dental plan, APTC, or CSR through the Exchange.

(55) "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.

(56) "Stand-alone dental plan (SADP)" means a qualified dental plan that meets the requirements under 45 CFR § 155.1065(a).

(57) "Zero cost sharing plan variation" means the cost-sharing reduction plan variation of a QHP under 45 CFR § 156.420(b)(1).

Md. Code Regs. 14.35.01.02

Regulation .02 amended effective 46:5 Md. R. 306, eff. 3/11/2019; amended effective 51:15 Md. R. 710, eff. 8/5/2024.