2013 Maryland Code
INSURANCE
§ 15-1301 - Definitions [Amendment subject to abrogation] [Effective until January 1, 2014]
§15-1301. IN EFFECT
(a) In this subtitle the following words have the meanings indicated.
(b) “Affiliation period” means a period of time beginning on the date of enrollment and not to exceed 2 months, or 3 months in the case of a late enrollee, during which a health maintenance organization does not collect premium, and coverage issued does not become effective.
(c) “Association” or “bona fide association” means an association that:
(1) has been actively in existence for at least 5 years;
(2) has been formed and maintained in good faith for purposes other than obtaining insurance and does not condition membership on the purchase of association-sponsored insurance;
(3) does not condition membership in the association on any health status-related factor relating to an individual, and states so clearly in all membership and application materials;
(4) makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to the members or individuals eligible for coverage and states so clearly in all membership and application materials;
(5) does not make health insurance coverage offered through the association available other than in connection with membership in the association, and states so clearly in all marketing and application materials; and
(6) provides and annually updates information necessary for the Commissioner to determine whether or not the association meets the definition of bona fide association before qualifying as an association under this subtitle.
(d) “Carrier” means a person that is:
(1) an insurer that holds a certificate of authority in the State and provides health insurance in the State;
(2) a health maintenance organization that is licensed to operate in the State;
(3) a nonprofit health service plan that is licensed to operate in the State; or
(4) any other person or organization that provides health benefit plans subject to State insurance regulation.
(e) “Church plan” means a plan as defined under § 3(33) of the Employee Retirement Income Security Act of 1974.
(f) (1) “Creditable coverage” means coverage of an individual under:
(i) an employer sponsored plan;
(ii) a health benefit plan;
(iii) Part A or Part B of Title XVIII of the Social Security Act;
(iv) Title XIX or Title XXI of the Social Security Act, other than coverage consisting solely of benefits under § 1928 of that Act;
(v) Chapter 55 of Title 10 of the United States Code;
(vi) a medical care program of the Indian Health Service or of a tribal organization;
(vii) a State health benefits risk pool;
(viii) a health plan offered under the Federal Employees Health Benefits Program (FEHBP), Title 5, Chapter 89 of the United States Code;
(ix) a public health plan as defined by federal regulations authorized by the Public Health Service Act, § 2701(c)(1)(i), as amended by P.L. 104-191; or
(x) a health benefit plan under § 5(e) of the Peace Corps Act, 22 U.S.C. 2504(e).
(2) A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a health benefit plan or an employer sponsored plan, if, after such period and before the enrollment date, there was a 63-day period during all of which the individual was not covered under any creditable coverage.
(g) “Eligible individual” means an individual:
(1) (i) for whom, as of the date on which the individual seeks coverage under this subtitle, the aggregate of the periods of creditable coverage is 18 or more months; and
(ii) whose most recent prior creditable coverage was under an employer sponsored plan, governmental plan, church plan, or health benefit plan offered in connection with any of these plans;
(2) who is not eligible for coverage under:
(i) an employer sponsored plan;
(ii) Part A or Part B of Title XVIII of the Social Security Act; or
(iii) a State plan under Title XIX of the Social Security Act;
(3) who does not have coverage under a health benefit plan;
(4) who has not had the most recent prior creditable coverage described in paragraph (1)(ii) of this subsection terminated for nonpayment of premiums or fraud by the individual; and
(5) who, if the individual has been offered the option of continuation coverage under a State or federal continuation provision:
(i) has elected that coverage; and
(ii) has exhausted that coverage.
(h) “Employer sponsored plan” means an employee welfare benefit plan that provides medical care to employees or their dependents, and is not subject to State regulation in accordance with the federal Employee Retirement Income Security Act of 1974.
(i) “Enrollment date” means the date on which:
(1) an individual enrolls in a health benefit plan; or
(2) the first day of the waiting period before which the individual may enroll.
(j) “Governmental plan” means a plan as defined in § 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan.
(k) (1) “Health benefit plan” means a:
(i) hospital or medical policy or certificate, including those issued under multiple employer trusts or associations located in Maryland or any other state covering Maryland residents;
(ii) policy, contract, or certificate issued by a nonprofit health service plan that covers Maryland residents; or
(iii) health maintenance organization subscriber or group master contract.
(2) “Health benefit plan” does not include:
(i) one or more, or any combination of the following:
1. coverage only for accident or disability income insurance;
2. coverage issued as a supplement to liability insurance;
3. liability insurance, including general liability insurance and automobile liability insurance;
4. workers’ compensation or similar insurance;
5. automobile medical payment insurance;
6. credit-only insurance;
7. coverage for on-site medical clinics; and
8. other similar insurance coverage, specified in federal regulations issued pursuant to P.L. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits;
(ii) the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of a plan:
1. limited scope dental or vision benefits;
2. benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these benefits; and
3. such other similar, limited benefits as are specified in federal regulations issued pursuant to P.L. 104-191;
(iii) the following benefits if offered as independent, noncoordinated benefits:
1. coverage only for a specified disease or illness; and
2. hospital indemnity or other fixed indemnity insurance; or
(iv) the following benefits if offered as a separate insurance policy:
1. Medicare supplemental health insurance (as defined under § 1882(g)(1) of the Social Security Act);
2. coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and
3. similar supplemental coverage provided to coverage under an employer sponsored plan.
(l) “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.
(m) “High level policy form” means a policy or plan under which the actuarial value of the benefit under the coverage is:
(1) at least 15% greater than the actuarial value of the low level policy form coverage offered by the carrier in this State; and
(2) at least 100% but not greater than 120% of the weighted average.
(n) (1) “Individual health benefit plan” means:
(i) a health benefit plan other than a converted policy or a professional association plan for eligible individuals and their dependents; and
(ii) a certificate issued to an eligible individual that evidences coverage under a policy or contract issued to a trust or association or other similar group of individuals, regardless of the situs of delivery of the policy or contract, if the eligible individual pays the premium and is not being covered under the policy or contract under either federal or State continuation of benefits provisions.
(2) “Individual health benefit plan” does not include short-term limited duration insurance.
(o) “Low level policy form” means a policy or plan under which the actuarial value of the benefit under the coverage is at least 85% but not greater than 100% of the weighted average.
(p) “Preexisting condition” means a condition that was present before the date of enrollment for coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.
(q) “Waiting period” means the period of time that must pass before an individual is eligible to be covered for benefits under the terms of a group health benefit plan.
(r) (1) “Weighted average” means the average actuarial value of the benefits provided by:
(i) all the health insurance coverages issued by the carrier in this State in the individual market during the previous calendar year, weighted by enrollment for the different coverages; or
(ii) all the health insurance coverages issued by all carriers in this State in the individual market, if the data are available, during the previous calendar year, weighted by enrollment for the different coverages.
(2) “Weighted average” does not include coverages issued under this subtitle.
15-1301.
// EFFECTIVE JUNE 30, 2014 PER CHAPTER 734 OF 2010 //
(a) In this subtitle the following words have the meanings indicated.
(b) “Affiliation period” means a period of time beginning on the date of enrollment and not to exceed 2 months, or 3 months in the case of a late enrollee, during which a health maintenance organization does not collect premium, and coverage issued does not become effective.
(c) “Association” or “bona fide association” means an association that:
(1) has been actively in existence for at least 5 years;
(2) has been formed and maintained in good faith for purposes other than obtaining insurance and does not condition membership on the purchase of association-sponsored insurance;
(3) does not condition membership in the association on any health status-related factor relating to an individual, and states so clearly in all membership and application materials;
(4) makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to the members or individuals eligible for coverage and states so clearly in all membership and application materials;
(5) does not make health insurance coverage offered through the association available other than in connection with membership in the association, and states so clearly in all marketing and application materials; and
(6) provides and annually updates information necessary for the Commissioner to determine whether or not the association meets the definition of bona fide association before qualifying as an association under this subtitle.
(d) “Carrier” means a person that is:
(1) an insurer that holds a certificate of authority in the State and provides health insurance in the State;
(2) a health maintenance organization that is licensed to operate in the State;
(3) a nonprofit health service plan that is licensed to operate in the State; or
(4) any other person or organization that provides health benefit plans subject to State insurance regulation.
(e) “Church plan” means a plan as defined under § 3(33) of the Employee Retirement Income Security Act of 1974.
(f) (1) “Creditable coverage” means coverage of an individual under:
(i) an employer sponsored plan;
(ii) a health benefit plan;
(iii) Part A or Part B of Title XVIII of the Social Security Act;
(iv) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under § 1928 of that Act;
(v) Chapter 55 of Title 10 of the United States Code;
(vi) a medical care program of the Indian Health Service or of a tribal organization;
(vii) a State health benefits risk pool;
(viii) a health plan offered under the Federal Employees Health Benefits Program (FEHBP), Title 5, Chapter 89 of the United States Code;
(ix) a public health plan as defined by federal regulations authorized by the Public Health Service Act, § 2701(c)(1)(i), as amended by P.L. 104-191; or
(x) a health benefit plan under § 5(e) of the Peace Corps Act, 22 U.S.C. 2504(e).
(2) A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a health benefit plan or an employer sponsored plan, if, after such period and before the enrollment date, there was a 63-day period during all of which the individual was not covered under any creditable coverage.
(g) “Eligible individual” means an individual:
(1) (i) for whom, as of the date on which the individual seeks coverage under this subtitle, the aggregate of the periods of creditable coverage is 18 or more months; and
(ii) whose most recent prior creditable coverage was under an employer sponsored plan, governmental plan, church plan, or health benefit plan offered in connection with any of these plans;
(2) who is not eligible for coverage under:
(i) an employer sponsored plan;
(ii) Part A or Part B of Title XVIII of the Social Security Act; or
(iii) a State plan under Title XIX of the Social Security Act;
(3) who does not have coverage under a health benefit plan;
(4) who has not had the most recent prior creditable coverage described in paragraph (1)(ii) of this subsection terminated for nonpayment of premiums or fraud by the individual; and
(5) who, if the individual has been offered the option of continuation coverage under a State or federal continuation provision:
(i) has elected that coverage; and
(ii) has exhausted that coverage.
(h) “Employer sponsored plan” means an employee welfare benefit plan that provides medical care to employees or their dependents, and is not subject to State regulation in accordance with the federal Employee Retirement Income Security Act of 1974.
(i) “Enrollment date” means the date on which:
(1) an individual enrolls in a health benefit plan; or
(2) the first day of the waiting period before which the individual may enroll.
(j) “Governmental plan” means a plan as defined in § 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan.
(k) (1) “Health benefit plan” means a:
(i) hospital or medical policy or certificate, including those issued under multiple employer trusts or associations located in Maryland or any other state covering Maryland residents;
(ii) policy, contract, or certificate issued by a nonprofit health service plan that covers Maryland residents; or
(iii) health maintenance organization subscriber or group master contract.
(2) “Health benefit plan” does not include:
(i) one or more, or any combination of the following:
1. coverage only for accident or disability income insurance;
2. coverage issued as a supplement to liability insurance;
3. liability insurance, including general liability insurance and automobile liability insurance;
4. workers’ compensation or similar insurance;
5. automobile medical payment insurance;
6. credit-only insurance;
7. coverage for on-site medical clinics; and
8. other similar insurance coverage, specified in federal regulations issued pursuant to P.L. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits;
(ii) the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of a plan:
1. limited scope dental or vision benefits;
2. benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these benefits; and
3. such other similar, limited benefits as are specified in federal regulations issued pursuant to P.L. 104-191;
(iii) the following benefits if offered as independent, noncoordinated benefits:
1. coverage only for a specified disease or illness; and
2. hospital indemnity or other fixed indemnity insurance; or
(iv) the following benefits if offered as a separate insurance policy:
1. Medicare supplemental health insurance (as defined under § 1882(g)(1) of the Social Security Act);
2. coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and
3. similar supplemental coverage provided to coverage under an employer sponsored plan.
(l) “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.
(m) “High level policy form” means a policy or plan under which the actuarial value of the benefit under the coverage is:
(1) at least 15% greater than the actuarial value of the low level policy form coverage offered by the carrier in this State; and
(2) at least 100% but not greater than 120% of the weighted average.
(n) (1) “Individual health benefit plan” means:
(i) a health benefit plan other than a converted policy or a professional association plan for eligible individuals and their dependents; and
(ii) a certificate issued to an eligible individual that evidences coverage under a policy or contract issued to a trust or association or other similar group of individuals, regardless of the situs of delivery of the policy or contract, if the eligible individual pays the premium and is not being covered under the policy or contract under either federal or State continuation of benefits provisions.
(2) “Individual health benefit plan” does not include short-term limited duration insurance.
(o) “Low level policy form” means a policy or plan under which the actuarial value of the benefit under the coverage is at least 85% but not greater than 100% of the weighted average.
(p) “Preexisting condition” means a condition that was present before the date of enrollment for coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.
(q) “Waiting period” means the period of time that must pass before an individual is eligible to be covered for benefits under the terms of a group health benefit plan.
(r) (1) “Weighted average” means the average actuarial value of the benefits provided by:
(i) all the health insurance coverages issued by the carrier in this State in the individual market during the previous calendar year, weighted by enrollment for the different coverages; or
(ii) all the health insurance coverages issued by all carriers in this State in the individual market, if the data are available, during the previous calendar year, weighted by enrollment for the different coverages.
(2) “Weighted average” does not include coverages issued under this subtitle.
§ 15-1301 - Definitions [Amendment subject to abrogation] [Effective January 1, 2014]
(a) In general. -- In this subtitle the following words have the meanings indicated.
(b) Affiliation period. -- "Affiliation period" means a period of time beginning on the date of enrollment and not to exceed 2 months, or 3 months in the case of a late enrollee, during which a health maintenance organization does not collect premium, and coverage issued does not become effective.
(c) Association; bona fide association. -- "Association" or "bona fide association" means an association that:
(1) has been actively in existence for at least 5 years;
(2) has been formed and maintained in good faith for purposes other than obtaining insurance and does not condition membership on the purchase of association-sponsored insurance;
(3) does not condition membership in the association on any health status-related factor relating to an individual, and states so clearly in all membership and application materials;
(4) makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to the members or individuals eligible for coverage and states so clearly in all membership and application materials;
(5) does not make health insurance coverage offered through the association available other than in connection with membership in the association, and states so clearly in all marketing and application materials; and
(6) provides and annually updates information necessary for the Commissioner to determine whether or not the association meets the definition of bona fide association before qualifying as an association under this subtitle.
(d) Benefit year. -- "Benefit year" means a calendar year in which a health benefit plan provides coverage for health benefits.
(e) Carrier. -- "Carrier" means a person that is:
(1) an insurer that holds a certificate of authority in the State and provides health insurance in the State;
(2) a health maintenance organization that is licensed to operate in the State;
(3) a nonprofit health service plan that is licensed to operate in the State; or
(4) any other person or organization that provides health benefit plans subject to State insurance regulation.
(f) Church plan. -- "Church plan" means a plan as defined under § 3(33) of the Employee Retirement Income Security Act of 1974.
(g) Creditable coverage. --
(1) "Creditable coverage" means coverage of an individual under:
(i) an employer sponsored plan;
(ii) a health benefit plan;
(iii) Part A or Part B of Title XVIII of the Social Security Act;
(iv) Title XIX or Title XXI of the Social Security Act, other than coverage consisting solely of benefits under § 1928 of that Act;
(v) Chapter 55 of Title 10 of the United States Code;
(vi) a medical care program of the Indian Health Service or of a tribal organization;
(vii) a State health benefits risk pool;
(viii) a health plan offered under the Federal Employees Health Benefits Program (FEHBP), Title 5, Chapter 89 of the United States Code;
(ix) a public health plan as defined by federal regulations authorized by the Public Health Service Act, § 2701(c)(1)(i), as amended by P.L. 104-191; or
(x) a health benefit plan under § 5(e) of the Peace Corps Act, 22 U.S.C. 2504(e).
(2) A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a health benefit plan or an employer sponsored plan, if, after such period and before the enrollment date, there was a 63-day period during all of which the individual was not covered under any creditable coverage.
(h) Eligible individual. -- "Eligible individual" means an individual:
(1) (i) for whom, as of the date on which the individual seeks coverage under this subtitle, the aggregate of the periods of creditable coverage is 18 or more months; and
(ii) whose most recent prior creditable coverage was under an employer sponsored plan, governmental plan, church plan, or health benefit plan offered in connection with any of these plans;
(2) who is not eligible for coverage under:
(i) an employer sponsored plan;
(ii) Part A or Part B of Title XVIII of the Social Security Act; or
(iii) a State plan under Title XIX of the Social Security Act;
(3) who does not have coverage under a health benefit plan;
(4) who has not had the most recent prior creditable coverage described in paragraph (1)(ii) of this subsection terminated for nonpayment of premiums or fraud by the individual; and
(5) who, if the individual has been offered the option of continuation coverage under a State or federal continuation provision:
(i) has elected that coverage; and
(ii) has exhausted that coverage.
(i) Employer sponsored plan. -- "Employer sponsored plan" means an employee welfare benefit plan that provides medical care to employees or their dependents, and is not subject to State regulation in accordance with the federal Employee Retirement Income Security Act of 1974.
(j) Enrollment date. -- "Enrollment date" means the date on which:
(1) an individual enrolls in a health benefit plan; or
(2) the first day of the waiting period before which the individual may enroll.
(k) Governmental plan. -- "Governmental plan" means a plan as defined in § 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan.
(l) Health benefit plan. --
(1) "Health benefit plan" means a:
(i) hospital or medical policy or certificate, including those issued under multiple employer trusts or associations located in Maryland or any other state covering Maryland residents;
(ii) policy, contract, or certificate issued by a nonprofit health service plan that covers Maryland residents; or
(iii) health maintenance organization subscriber or group master contract.
(2) "Health benefit plan" does not include:
(i) one or more, or any combination of the following:
1. coverage only for accident or disability income insurance;
2. coverage issued as a supplement to liability insurance;
3. liability insurance, including general liability insurance and automobile liability insurance;
4. workers' compensation or similar insurance;
5. automobile medical payment insurance;
6. credit-only insurance;
7. coverage for on-site medical clinics; and
8. other similar insurance coverage, specified in federal regulations issued pursuant to P.L. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits;
(ii) the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of a plan:
1. limited scope dental or vision benefits;
2. benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these benefits; and
3. such other similar, limited benefits as are specified in federal regulations issued pursuant to P.L. 104-191;
(iii) the following benefits if offered as independent, noncoordinated benefits:
1. coverage only for a specified disease or illness; and
2. hospital indemnity or other fixed indemnity insurance; or
(iv) the following benefits if offered as a separate insurance policy:
1. Medicare supplemental health insurance (as defined under § 1882(g)(1) of the Social Security Act);
2. coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and
3. similar supplemental coverage provided to coverage under an employer sponsored plan.
(m) 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.
(n) High level policy form. -- "High level policy form" means a policy or plan under which the actuarial value of the benefit under the coverage is:
(1) at least 15% greater than the actuarial value of the low level policy form coverage offered by the carrier in this State; and
(2) at least 100% but not greater than 120% of the weighted average.
(o) Individual Exchange. -- "Individual Exchange" has the meaning stated in § 31-101 of this article.
(p Individual health benefit plan. --
(1) "Individual health benefit plan" means:
(i) a health benefit plan other than a converted policy or a professional association plan for eligible individuals and their dependents; and
(ii) a certificate issued to an eligible individual that evidences coverage under a policy or contract issued to a trust or association or other similar group of individuals, regardless of the situs of delivery of the policy or contract, if the eligible individual pays the premium and is not being covered under the policy or contract under either federal or State continuation of benefits provisions.
(2) "Individual health benefit plan" does not include short-term limited duration insurance.
(q) Low level policy form. -- "Low level policy form" means a policy or plan under which the actuarial value of the benefit under the coverage is at least 85% but not greater than 100% of the weighted average.
(r) Minimum essential coverage. -- "Minimum essential coverage" has the meaning stated in 45 C.F.R. § 155.20.
(s) Preexisting condition. -- "Preexisting condition" means a condition that was present before the date of enrollment for coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.
(t) Qualified health plan. -- "Qualified health plan" has the meaning stated in § 31-101 of this article.
(u) Waiting period. -- "Waiting period" means the period of time that must pass before an individual is eligible to be covered for benefits under the terms of a group health benefit plan.
(v) Weighted average. --
(1) "Weighted average" means the average actuarial value of the benefits provided by:
(i) all the health insurance coverages issued by the carrier in this State in the individual market during the previous calendar year, weighted by enrollment for the different coverages; or
(ii) all the health insurance coverages issued by all carriers in this State in the individual market, if the data are available, during the previous calendar year, weighted by enrollment for the different coverages.
(2) "Weighted average" does not include coverages issued under this subtitle.
§ 15-1301 - Definitions (Abrogation of amendment effective June 30, 2014.)
(a) In general. -- In this subtitle the following words have the meanings indicated.
(b) Affiliation period. -- "Affiliation period" means a period of time beginning on the date of enrollment and not to exceed 2 months, or 3 months in the case of a late enrollee, during which a health maintenance organization does not collect premium, and coverage issued does not become effective.
(c) Association; bona fide association. -- "Association" or "bona fide association" means an association that:
(1) has been actively in existence for at least 5 years;
(2) has been formed and maintained in good faith for purposes other than obtaining insurance and does not condition membership on the purchase of association-sponsored insurance;
(3) does not condition membership in the association on any health status-related factor relating to an individual, and states so clearly in all membership and application materials;
(4) makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to the members or individuals eligible for coverage and states so clearly in all membership and application materials;
(5) does not make health insurance coverage offered through the association available other than in connection with membership in the association, and states so clearly in all marketing and application materials; and
(6) provides and annually updates information necessary for the Commissioner to determine whether or not the association meets the definition of bona fide association before qualifying as an association under this subtitle.
(d) Carrier. -- "Carrier" means a person that is:
(1) an insurer that holds a certificate of authority in the State and provides health insurance in the State;
(2) a health maintenance organization that is licensed to operate in the State;
(3) a nonprofit health service plan that is licensed to operate in the State; or
(4) any other person or organization that provides health benefit plans subject to State insurance regulation.
(e) Church plan. -- "Church plan" means a plan as defined under § 3(33) of the Employee Retirement Income Security Act of 1974.
(f) Creditable coverage. --
(1) "Creditable coverage" means coverage of an individual under:
(i) an employer sponsored plan;
(ii) a health benefit plan;
(iii) Part A or Part B of Title XVIII of the Social Security Act;
(iv) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under § 1928 of that Act;
(v) Chapter 55 of Title 10 of the United States Code;
(vi) a medical care program of the Indian Health Service or of a tribal organization;
(vii) a State health benefits risk pool;
(viii) a health plan offered under the Federal Employees Health Benefits Program (FEHBP), Title 5, Chapter 89 of the United States Code;
(ix) a public health plan as defined by federal regulations authorized by the Public Health Service Act, § 2701(c)(1)(i), as amended by P.L. 104-191; or
(x) a health benefit plan under § 5(e) of the Peace Corps Act, 22 U.S.C. 2504(e).
(2) A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a health benefit plan or an employer sponsored plan, if, after such period and before the enrollment date, there was a 63-day period during all of which the individual was not covered under any creditable coverage.
(g) Eligible individual. -- "Eligible individual" means an individual:
(1) (i) for whom, as of the date on which the individual seeks coverage under this subtitle, the aggregate of the periods of creditable coverage is 18 or more months; and
(ii) whose most recent prior creditable coverage was under an employer sponsored plan, governmental plan, church plan, or health benefit plan offered in connection with any of these plans;
(2) who is not eligible for coverage under:
(i) an employer sponsored plan;
(ii) Part A or Part B of Title XVIII of the Social Security Act; or
(iii) a State plan under Title XIX of the Social Security Act;
(3) who does not have coverage under a health benefit plan;
(4) who has not had the most recent prior creditable coverage described in paragraph (1)(ii) of this subsection terminated for nonpayment of premiums or fraud by the individual; and
(5) who, if the individual has been offered the option of continuation coverage under a State or federal continuation provision:
(i) has elected that coverage; and
(ii) has exhausted that coverage.
(h) Employer sponsored plan. -- "Employer sponsored plan" means an employee welfare benefit plan that provides medical care to employees or their dependents, and is not subject to State regulation in accordance with the federal Employee Retirement Income Security Act of 1974.
(i) Enrollment date. -- "Enrollment date" means the date on which:
(1) an individual enrolls in a health benefit plan; or
(2) the first day of the waiting period before which the individual may enroll.
(j) Governmental plan. -- "Governmental plan" means a plan as defined in § 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan.
(k) Health benefit plan. --
(1) "Health benefit plan" means a:
(i) hospital or medical policy or certificate, including those issued under multiple employer trusts or associations located in Maryland or any other state covering Maryland residents;
(ii) policy, contract, or certificate issued by a nonprofit health service plan that covers Maryland residents; or
(iii) health maintenance organization subscriber or group master contract.
(2) "Health benefit plan" does not include:
(i) one or more, or any combination of the following:
1. coverage only for accident or disability income insurance;
2. coverage issued as a supplement to liability insurance;
3. liability insurance, including general liability insurance and automobile liability insurance;
4. workers' compensation or similar insurance;
5. automobile medical payment insurance;
6. credit-only insurance;
7. coverage for on-site medical clinics; and
8. other similar insurance coverage, specified in federal regulations issued pursuant to P.L. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits;
(ii) the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of a plan:
1. limited scope dental or vision benefits;
2. benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these benefits; and
3. such other similar, limited benefits as are specified in federal regulations issued pursuant to P.L. 104-191;
(iii) the following benefits if offered as independent, noncoordinated benefits:
1. coverage only for a specified disease or illness; and
2. hospital indemnity or other fixed indemnity insurance; or
(iv) the following benefits if offered as a separate insurance policy:
1. Medicare supplemental health insurance (as defined under § 1882(g)(1) of the Social Security Act);
2. coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and
3. similar supplemental coverage provided to coverage under an employer sponsored plan.
(l) 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.
(m) High level policy form. -- "High level policy form" means a policy or plan under which the actuarial value of the benefit under the coverage is:
(1) at least 15% greater than the actuarial value of the low level policy form coverage offered by the carrier in this State; and
(2) at least 100% but not greater than 120% of the weighted average.
(n) Individual health benefit plan. --
(1) "Individual health benefit plan" means:
(i) a health benefit plan other than a converted policy or a professional association plan for eligible individuals and their dependents; and
(ii) a certificate issued to an eligible individual that evidences coverage under a policy or contract issued to a trust or association or other similar group of individuals, regardless of the situs of delivery of the policy or contract, if the eligible individual pays the premium and is not being covered under the policy or contract under either federal or State continuation of benefits provisions.
(2) "Individual health benefit plan" does not include short-term limited duration insurance.
(o) Low level policy form. -- "Low level policy form" means a policy or plan under which the actuarial value of the benefit under the coverage is at least 85% but not greater than 100% of the weighted average.
(p) Preexisting condition. -- "Preexisting condition" means a condition that was present before the date of enrollment for coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.
(q) Waiting period. -- "Waiting period" means the period of time that must pass before an individual is eligible to be covered for benefits under the terms of a group health benefit plan.
(r) Weighted average. --
(1) "Weighted average" means the average actuarial value of the benefits provided by:
(i) all the health insurance coverages issued by the carrier in this State in the individual market during the previous calendar year, weighted by enrollment for the different coverages; or
(ii) all the health insurance coverages issued by all carriers in this State in the individual market, if the data are available, during the previous calendar year, weighted by enrollment for the different coverages.
(2) "Weighted average" does not include coverages issued under this subtitle.
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