2013 Maryland Code
INSURANCE
§ 15-1316 - Annual open enrollment period [Effective January 1, 2014].

(a) Definitions. --

(1) In this section the following words have the meanings indicated.

(2) "Dependent" means an individual who is or who may become eligible for coverage under the terms of a health benefit plan because of a relationship with another individual.

(3) "Qualifying coverage in an eligible employer-sponsored plan" has the meaning stated in 45 C.F.R. § 155.300.

(b) In general. --

(1) Beginning October 15, 2014, a carrier that sells health benefit plans to individuals in the State shall establish an annual open enrollment period.

(2) The annual open enrollment period shall begin on October 15 and extend through December 7 each year.

(3) During the annual open enrollment period, an individual shall be permitted to:

(i) enroll in a health benefit plan offered by the carrier;

(ii) discontinue enrollment in a health benefit plan offered by the carrier; or

(iii) change enrollment in a health benefit plan offered by the carrier to a different health benefit plan offered by the carrier.

(4) If an individual enrolls in a health benefit plan offered by the carrier during the annual open enrollment period, the effective date of coverage shall be January 1 of the following calendar year.

(c) Special open enrollment period for indiviuals who experience triggering event. --

(1) A carrier shall provide a special open enrollment period for each individual who experiences a triggering event.

(2) The special open enrollment period shall be for at least 60 days, beginning on the date of the triggering event.

(3) During the special open enrollment period, a carrier shall permit an individual who experiences a triggering event to enroll in or change from one health benefit plan offered by the carrier to another health benefit plan offered by the carrier.

(4) A triggering event occurs when:

(i) subject to paragraph (5) of this subsection, an individual or dependent loses minimum essential coverage;

(ii) an individual gains a dependent or becomes a dependent through marriage, birth, adoption, or placement for adoption;

(iii) an individual's or a dependent's enrollment or nonenrollment in a qualified health plan is, as evaluated and determined by the Individual Exchange:

1. unintentional, inadvertent, or erroneous; and

2. the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Individual Exchange or the U.S. Department of Health and Human Services or its instrumentalities;

(iv) an individual or a dependent who is enrolled in a qualified health plan in the Individual Exchange adequately demonstrates to the Individual Exchange that the qualified health plan in which the individual or dependent is enrolled substantially violated a material provision of the qualified health plan's contract in relation to the individual or dependent;

(v) an individual or a dependent enrolled in the same health benefit plan is determined newly eligible or newly ineligible for advance payments of federal premium tax credits or has a change in eligibility for federal cost-sharing reductions;

(vi) an individual or a dependent gains access to a new health benefit plan as a result of a permanent move;

(vii) the individual or dependent is enrolled in an employer-sponsored health benefit plan that is not qualifying coverage in an eligible employer-sponsored plan and is allowed to terminate existing coverage; or

(viii) for a health benefit plan offered through the Individual Exchange:

1. an individual who was not previously a citizen, national, or lawfully present individual becomes a citizen, national, or lawfully present individual; or

2. an individual or a dependent demonstrates to the Individual Exchange, in accordance with guidelines issued by the U.S. Department of Health and Human Services, that the individual or dependent meets other exceptional circumstances as the Individual Exchange may provide.

(5) Loss of minimum essential coverage under paragraph (4)(i) of this subsection does not include loss of coverage due to:

(i) failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; or

(ii) a rescission authorized under 45 C.F.R. § 147.128.

(6) If a triggering event described in paragraph (4)(iii) of this subsection occurs, the Individual Exchange may take action as may be necessary to correct or eliminate the effects of the error, misrepresentation, or inaction.

(7) If a triggering event described in paragraph (4)(v) of this subsection occurs, a carrier shall permit an individual or a dependent, whose existing coverage through an employer-sponsored plan will no longer be affordable or provide minimum value for the upcoming plan year of the individual's employer, to access the special open enrollment period before the end of the individual's coverage through the employer-sponsored plan.

(8) If an individual or a dependent meets the requirements for the triggering event described in paragraph (4)(vii) of this subsection, the special open enrollment period shall begin at least 60 days before the end of the individual's or dependent's coverage under the employer-sponsored plan.

(d) Provision for Indians. -- An individual who is an Indian, as defined in § 4 of the federal Indian Health Care Improvement Act, may enroll in a health benefit plan in the Individual Exchange or change from one health benefit plan in the Individual Exchange to another health benefit plan in the Individual Exchange one time per month.

(e) Limited open enrollment period for individuals enrolled in noncalendar year individual health benefit plan. --

(1) A carrier shall provide a limited open enrollment period for an individual who is enrolled in a noncalendar year individual health benefit plan to enroll in a health benefit plan issued by the carrier.

(2) The limited enrollment period required by paragraph (1) of this subsection shall:

(i) begin on the date that is at least 30 calendar days before the date the noncalendar year health benefit plan's policy year ends in 2014; and

(ii) last at least 60 days.

(f) Effectiveness of coverage. -- If an individual enrolls for coverage during one of the open enrollment or special open enrollment periods described in this section, coverage shall be effective in accordance with the requirements in 45 C.F.R. § 155.420.

(g) Powers of health maintenance organizations. --

(1) A health maintenance organization may:

(i) limit the individuals who may apply for coverage to those who live or reside in the health maintenance organization's service area; and

(ii) deny coverage to individuals if the health maintenance organization has demonstrated to the Commissioner that:

1. it will not have the capacity to deliver services adequately to any additional individuals because of its obligations to existing enrollees; and

2. it is applying the provisions of this paragraph uniformly to all individuals without regard to the claims experience of those individuals and their dependents or any health status-related factor relating to the individuals and their dependents.

(2) A health maintenance organization that denies coverage to an individual in accordance with paragraph (1) of this subsection may not offer coverage in the individual market within the service area to any individual for a period of 180 days after the date the coverage is denied.

(3) Paragraph (2) of this subsection does not:

(i) limit the health maintenance organization's ability to renew coverage already in force; or

(ii) relieve the health maintenance organization of the responsibility to renew coverage already in force.

(h) Requirements for denial of health benefit plan for individual. --

(1) A carrier may deny a health benefit plan to an individual if the carrier has demonstrated to the Commissioner that:

(i) it does not have the financial reserves necessary to offer additional coverage; and

(ii) it is applying the provisions of this paragraph uniformly to all individuals in the individual market in the State without regard to the claims experience of those individuals and their dependents or any health status-related factor relating to the individuals and their dependents.

(2) A carrier that denies a health benefit plan to an individual in the State under paragraph (1) of this subsection may not offer coverage in the individual market before the later of:

(i) the 181st day after the date the carrier denies coverage; and

(ii) the date the carrier demonstrates to the Commissioner that the carrier has sufficient financial reserves to underwrite additional coverage.

(3) Paragraph (2) of this subsection does not:

(i) limit the carrier's ability to renew coverage already in force; or

(ii) relieve the carrier of the responsibility to renew coverage already in force.

(4) Health benefit plans offered after the time period described in paragraph (2) of this subsection are subject to the requirements of this section.