2013 Maryland Code
INSURANCE
§ 15-1201 - Definitions [Effective until January 1, 2014]


MD Ins Code § 15-1201 (2013) What's This?

§15-1201. IN EFFECT

(a) In this subtitle the following words have the meanings indicated.

(b) “Board” means the Board of Directors of the Pool established under § 15-1216 of this subtitle.

(c) “Carrier” means a person that:

(1) offers health benefit plans in the State covering eligible employees of small employers; and

(2) is:

(i) an authorized insurer that provides health insurance in the State;

(ii) a nonprofit health service plan that is licensed to operate in the State;

(iii) a health maintenance organization that is licensed to operate in the State; or

(iv) any other person or organization that provides health benefit plans subject to State insurance regulation.

(d) “Commission” means the Maryland Health Care Commission established under Title 19, Subtitle 1 of the Health - General Article.

(e) (1) “Eligible employee” means:

(i) an individual who:

1. is an employee, partner of a partnership, or independent contractor who is included as an employee under a health benefit plan; and

2. works on a full-time basis and has a normal workweek of at least 30 hours; or

(ii) a sole employee of a nonprofit organization that has been determined by the Internal Revenue Service to be exempt from taxation under § 501(c)(3), (4), or (6) of the Internal Revenue Code who:

1. has a normal workweek of at least 20 hours; and

2. is not covered under a public or private plan for health insurance or other health benefit arrangement.

(2) “Eligible employee” does not include an individual who works:

(i) on a temporary or substitute basis; or

(ii) except for an individual described in paragraph (1)(ii) of this subsection, for less than 30 hours in a normal workweek.

(f) (1) “Health benefit plan” means:

(i) a policy or certificate for hospital or medical benefits;

(ii) a nonprofit health service plan; or

(iii) a health maintenance organization subscriber or group master contract.

(2) “Health benefit plan” includes a policy or certificate for hospital or medical benefits that covers residents of this State who are eligible employees and that is issued through:

(i) a multiple employer trust or association located in this State or another state; or

(ii) a professional employer organization, coemployer, or other organization located in this State or another state that engages in employee leasing.

(3) “Health benefit plan” does not include:

(i) accident-only insurance;

(ii) fixed indemnity insurance;

(iii) credit health insurance;

(iv) Medicare supplement policies;

(v) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement policies;

(vi) long-term care insurance;

(vii) disability income insurance;

(viii) coverage issued as a supplement to liability insurance;

(ix) workers’ compensation or similar insurance;

(x) disease-specific insurance;

(xi) automobile medical payment insurance;

(xii) dental insurance; or

(xiii) vision insurance.

(g) “Health status-related factor” means a factor related to:

(1) health status;

(2) medical condition;

(3) claims experience;

(4) receipt of health care;

(5) medical history;

(6) genetic information;

(7) evidence of insurability including conditions arising out of acts of domestic violence; or

(8) disability.

(h) “Late enrollee” means an eligible employee or dependent who requests enrollment in a health benefit plan after the initial enrollment period provided under the health benefit plan.

(i) “Pool” means the Maryland Small Employer Health Reinsurance Pool established under this subtitle.

(j) “Preexisting condition” means:

(1) a condition existing during a specified period immediately preceding the effective date of coverage, that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment; or

(2) a condition for which medical advice, diagnosis, care, or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.

(k) “Preexisting condition provision” means a provision in a health benefit plan that denies, excludes, or limits benefits for an enrollee for expenses or services related to a preexisting condition.

(l) “Reinsuring carrier” means a carrier that participates in the Pool.

(m) “Risk-assuming carrier” means a carrier that does not participate in the Pool.

(n) “Small employer” means:

(1) an employer described in § 15-1203 of this subtitle; or

(2) an entity that leases employees from a professional employer organization, coemployer, or other organization engaged in employee leasing and that otherwise meets the description of § 15-1203 of this subtitle.

(o) “Special enrollment period” means a period during which a group health plan shall permit certain individuals who are eligible for coverage, but not enrolled, to enroll for coverage under the terms of the group health benefit plan.

(p) “Standard Plan” means the Comprehensive Standard Health Benefit Plan adopted by the Commission in accordance with § 15-1207 of this subtitle and Title 19, Subtitle 1 of the Health - General Article.

(q) (1) “Wellness program” means a program or activity that:

(i) is designed to improve health status and reduce health care costs; and

(ii) complies with guidelines developed by the Commission.

(2) “Wellness program” includes programs and activities for:

(i) smoking cessation;

(ii) reduction of alcohol misuse;

(iii) weight reduction;

(iv) nutrition education; and

(v) automobile and motorcycle safety.

(r) “Wellness benefit” means a benefit that:

(1) includes a bona fide wellness program as defined in § 15-509 of this title; and

(2) complies with regulations adopted by the Commission.

15-1201. // EFFECTIVE DECEMBER 31, 2013 PER CHAPTER 104 OF 2011 //

(a) In this subtitle the following words have the meanings indicated.

(b) “Board” means the Board of Directors of the Pool established under § 15-1216 of this subtitle.

(c) “Carrier” means a person that:

(1) offers health benefit plans in the State covering eligible employees of small employers; and

(2) is:

(i) an authorized insurer that provides health insurance in the State;

(ii) a nonprofit health service plan that is licensed to operate in the State;

(iii) a health maintenance organization that is licensed to operate in the State; or

(iv) any other person or organization that provides health benefit plans subject to State insurance regulation.

(d) “Commission” means the Maryland Health Care Commission established under Title 19, Subtitle 1 of the Health - General Article.

(e) (1) “Eligible employee” means:

(i) an individual who:

1. is an employee, sole proprietor, self-employed individual, partner of a partnership, or independent contractor who is included as an employee under a health benefit plan; and

2. works on a full-time basis and has a normal workweek of at least 30 hours; or

(ii) a sole employee of a nonprofit organization that has been determined by the Internal Revenue Service to be exempt from taxation under § 501(c)(3), (4), or (6) of the Internal Revenue Code who:

1. has a normal workweek of at least 20 hours; and

2. is not covered under a public or private plan for health insurance or other health benefit arrangement.

(2) “Eligible employee” does not include an individual who works:

(i) on a temporary or substitute basis; or

(ii) except for an individual described in paragraph (1)(ii) of this subsection, for less than 30 hours in a normal workweek.

(f) (1) “Health benefit plan” means:

(i) a policy or certificate for hospital or medical benefits;

(ii) a nonprofit health service plan; or

(iii) a health maintenance organization subscriber or group master contract.

(2) “Health benefit plan” includes a policy or certificate for hospital or medical benefits that covers residents of this State who are eligible employees and that is issued through:

(i) a multiple employer trust or association located in this State or another state; or

(ii) a professional employer organization, coemployer, or other organization located in this State or another state that engages in employee leasing.

(3) “Health benefit plan” does not include:

(i) accident-only insurance;

(ii) fixed indemnity insurance;

(iii) credit health insurance;

(iv) Medicare supplement policies;

(v) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement policies;

(vi) long-term care insurance;

(vii) disability income insurance;

(viii) coverage issued as a supplement to liability insurance;

(ix) workers’ compensation or similar insurance;

(x) disease-specific insurance;

(xi) automobile medical payment insurance;

(xii) dental insurance; or

(xiii) vision insurance.

(g) “Health status-related factor” means a factor related to:

(1) health status;

(2) medical condition;

(3) claims experience;

(4) receipt of health care;

(5) medical history;

(6) genetic information;

(7) evidence of insurability including conditions arising out of acts of domestic violence; or

(8) disability.

(h) “Late enrollee” means:

(1) an eligible employee or dependent who requests enrollment in a health benefit plan after the initial enrollment period provided under the health benefit plan; or

(2) a self-employed individual described in § 15-1203(c) or (d) of this subtitle or dependent who requests enrollment in a health benefit plan after an annual open enrollment period for self-employed individuals established by the carrier in accordance with regulations adopted by the Commissioner.

(i) “Pool” means the Maryland Small Employer Health Reinsurance Pool established under this subtitle.

(j) “Preexisting condition” means:

(1) a condition existing during a specified period immediately preceding the effective date of coverage, that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment; or

(2) a condition for which medical advice, diagnosis, care, or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.

(k) “Preexisting condition provision” means a provision in a health benefit plan that denies, excludes, or limits benefits for an enrollee for expenses or services related to a preexisting condition.

(l) “Reinsuring carrier” means a carrier that participates in the Pool.

(m) “Risk-assuming carrier” means a carrier that does not participate in the Pool.

(n) “Small employer” means:

(1) an employer described in § 15-1203 of this subtitle; or

(2) an entity that leases employees from a professional employer organization, coemployer, or other organization engaged in employee leasing and that otherwise meets the description of § 15-1203 of this subtitle.

(o) “Special enrollment period” means a period during which a group health plan shall permit certain individuals who are eligible for coverage, but not enrolled, to enroll for coverage under the terms of the group health benefit plan.

(p) “Standard Plan” means the Comprehensive Standard Health Benefit Plan adopted by the Commission in accordance with § 15-1207 of this subtitle and Title 19, Subtitle 1 of the Health - General Article.

(q) (1) “Wellness program” means a program or activity that:

(i) is designed to improve health status and reduce health care costs; and

(ii) complies with guidelines developed by the Commission.

(2) “Wellness program” includes programs and activities for:

(i) smoking cessation;

(ii) reduction of alcohol misuse;

(iii) weight reduction;

(iv) nutrition education; and

(v) automobile and motorcycle safety.

(r) “Wellness benefit” means a benefit that:

(1) includes a bona fide wellness program as defined in § 15-509 of this title; and

(2) complies with regulations adopted by the Commission.

§ 15-1201 - Definitions [Effective January 1, 2014]

(a) In general. -- In this subtitle the following words have the meanings indicated.

(b) Board. -- "Board" means the Board of Directors of the Pool established under § 15-1216 of this subtitle.

(c) Carrier. -- "Carrier" means a person that:

(1) offers health benefit plans in the State covering eligible employees of small employers; and

(2) is:

(i) an authorized insurer that provides health insurance in the State;

(ii) a nonprofit health service plan that is licensed to operate in the State;

(iii) a health maintenance organization that is licensed to operate in the State; or

(iv) any other person or organization that provides health benefit plans subject to State insurance regulation.

(d) Commission. -- "Commission" means the Maryland Health Care Commission established under Title 19, Subtitle 1 of the Health - General Article.

(e) Coverage level. -- "Coverage level" has the meaning stated in § 31-101 of this article.

(f) Eligible employee. --

(1) "Eligible employee" means an employee who is offered coverage under a health benefit plan by a small employer.

(2) "Eligible employee", at the option of the small employer, may include:

(i) only full-time employees; or

(ii) full-time employees and part-time employees.

(g) Employee. -- "Employee" means an individual who is employed by a small employer.

(h) Full-time employee. -- "Full-time employee" means an employee of a small employer who works, on average, at least 30 hours per week.

(i) Health benefit plan. --

(1) "Health benefit plan" means:

(i) a policy or certificate for hospital or medical benefits;

(ii) a nonprofit health service plan; or

(iii) a health maintenance organization subscriber or group master contract.

(2) "Health benefit plan" includes a policy or certificate for hospital or medical benefits that covers residents of this State who are eligible employees and that is issued through:

(i) a multiple employer trust or association located in this State or another state; or

(ii) a professional employer organization, coemployer, or other organization located in this State or another state that engages in employee leasing.

(3) "Health benefit plan" does not include:

(i) accident-only insurance;

(ii) fixed indemnity insurance;

(iii) credit health insurance;

(iv) Medicare supplement policies;

(v) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement policies;

(vi) long-term care insurance;

(vii) disability income insurance;

(viii) coverage issued as a supplement to liability insurance;

(ix) workers' compensation or similar insurance;

(x) disease-specific insurance;

(xi) automobile medical payment insurance;

(xii) dental insurance; or

(xiii) vision insurance.

(j) Health status-related factor. -- "Health status-related factor" means a factor related to:

(1) health status;

(2) medical condition;

(3) claims experience;

(4) receipt of health care;

(5) medical history;

(6) genetic information;

(7) evidence of insurability including conditions arising out of acts of domestic violence; or

(8) disability.

(k) Late enrollee. -- "Late enrollee" means an eligible employee or dependent who requests enrollment in a health benefit plan after the initial enrollment period provided under the health benefit plan.

(l) Minimum essential coverage. -- "Minimum essential coverage" has the meaning stated in 45 C.F.R. § 155.20.

(m) Part-time employee. -- "Part-time employee" means an employee of a small employer who:

(1) has a normal workweek of at least 17.5 hours; and

(2) is not a full-time employee.

(n) Plan year. -- "Plan year" means a calendar year or other consecutive 12-month period during which a health benefit plan provides coverage for health care services.

(o) Pool. -- "Pool" means the Maryland Small Employer Health Reinsurance Pool established under this subtitle.

(p) Preexisting condition. -- "Preexisting condition" means:

(1) a condition existing during a specified period immediately preceding the effective date of coverage, that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment; or

(2) a condition for which medical advice, diagnosis, care, or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.

(q) Preexisting condition provision. -- "Preexisting condition provision" means a provision in a health benefit plan that denies, excludes, or limits benefits for an enrollee for expenses or services related to a preexisting condition.

(r) Qualified employer. -- "Qualified employer" has the meaning stated in § 31-101 of this article.

(s) Qualified health plan. -- "Qualified health plan" has the meaning stated in § 31-101 of this article.

(t) Reinsuring carrier. -- "Reinsuring carrier" means a carrier that participates in the Pool.

(u) Risk-assuming carrier. -- "Risk-assuming carrier" means a carrier that does not participate in the Pool.

(v) SHOP Exchange. -- "SHOP Exchange" has the meaning stated in § 31-101 of this article.

(w) Small employer. -- "Small employer"

(1) an employer described in § 15-1203 of this subtitle; or

(2) an entity that leases employees from a professional employer organization, coemployer, or other organization engaged in employee leasing and that otherwise meets the description of § 15-1203 of this subtitle has the meaning stated in § 31-101 of this article.

(x) Special enrollment period. -- "Special enrollment period" means a period during which a group health plan shall permit certain individuals who are eligible for coverage, but not enrolled, to enroll for coverage under the terms of the group health benefit plan.

(y) Standard Plan. -- "Standard Plan" means the Comprehensive Standard Health Benefit Plan adopted by the Commission in accordance with § 15-1207 of this subtitle and Title 19, Subtitle 1 of the Health - General Article.

(z) Wellness program. --

(1) "Wellness program" means a program or activity that:

(i) is designed to improve health status and reduce health care costs; and

(ii) complies with guidelines developed by the Commission.

(2) "Wellness program" includes programs and activities for:

(i) smoking cessation;

(ii) reduction of alcohol misuse;

(iii) weight reduction;

(iv) nutrition education; and

(v) automobile and motorcycle safety.

(aa) Wellness benefit. -- "Wellness benefit" means a benefit that:

(1) includes a bona fide wellness program as defined in § 15-509 of this title; and

(2) complies with regulations adopted by the Commission.

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